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notes_small.csv

@@ -47,762 +47,820 @@ MEDQUIST36
 D:  2130-4-17  08:29
 T:  2130-4-18  08:31
 JOB#:  Job Number 20340"
-"Admission Date:  2188-1-12       Discharge Date:  2188-1-25
+"Admission Date:  2143-11-10              Discharge Date:   2143-12-11
 
-Date of Birth:   2148-1-24       Sex:  M
+Date of Birth:  2089-2-6             Sex:   M
 
-Service:
+Service: MEDICINE
 
-HISTORY OF PRESENT ILLNESS:  The patient is a 39 year old
-male who was an unrestrained driver involved in a rollover
-motor vehicle accident.  He was partially ejected from the
-vehicle.  He had a prolonged extrication time, approximately
-30 minutes and was found unresponsive by paramedics at the
-scene and intubated.  The patient was transferred to an
-outside medical facility where he had some left side crepitus
-noted.  He had a left chest tube placed for relief of this
-pneumothorax.  The patient, at that time, was noted to be
-hypotensive and had a diagnostic peritoneal lavage performed
-which was negative.  The patient's chest x-ray at that time
-showed a pneumothorax on the opposite side, on the right
-side, for which another chest tube was placed.  The patient
-was packaged and prepared for transfer through Flores Memorial Hospital, however, upon wheeling the patient
-away from that facility, he was found to be hypotensive
-initially and then had an asystolic arrest.  Two additional
-bilateral chest tubes were placed with relief of bilateral
-tension hemopneumothoraces with return of perfusing cardiac
-rhythm.
-
-The patient was stabilized for transfer to Flores Memorial Hospital.  Upon arrival in our Trauma Bay,
-the patient was intubated, sedated, and paralyzed.  The
-patient had three chest tubes in place and was
-hemodynamically stable.
-
-HOSPITAL COURSE:   Trauma work-up at our facility revealed
-bilateral pneumothoraces with minimal hemothoraces,
-adequately drained by his chest tubes.  However, persistent
-air leaks were noted and it was identified that the patient'a
-proximal ports of his chest tubes were out of the chest.
-During the CT scan, he became hypotensive and these tubes had
-to be emergently advanced with good result.
-
-The patient's trauma series revealed multiple rib fractures
-and hemopneumothoraces as stated above.  The patient had a
-head CT scan which was negative and a CT scan of the cervical
-spine which showed a tiny C5 avulsion fracture which was
-non-displaced.  CT scan of his chest revealed bilateral
-pulmonary contusions, bilateral consolidation and a left
-clavicular fracture.  CT scan of his abdomen and pelvis
-showed a minimal amount of free fluid consistent with his
-diagnostic left clavicular fracture.  CT scan of his abdomen
-and pelvis showed a minimum amount of free fluid consistent
-with his diagnostic peritoneal lavage.  The patient also
-noted to have multiple bilateral rib fractures.
-
-The patient's plain film also on a later read revealed
-question of a left iliac Dr. Sanchez fracture which was
-non-displaced.  The patient also was noted by a consultation
-by Orthopedic Surgeons to have a glenoid fracture in addition
-to a humerus fracture.
-
-The patient was transferred to the Surgical Intensive Care
-Unit where two fresh sterile chest tubes were placed and his
-three other chest tubes were removed.  He required
-intermittent pressor support and aggressive fluid
-resuscitation.  Neurosurgery was consulted and determined
-that this C5 fracture was nondisplaced, not requiring any
-specific therapy, however, that the patient should be in a
-hard collar for six weeks.
-
-The patient developed pulmonary infiltrate and some fevers
-for which he was started on Ceftriaxone for some Gram
-negative rods growing in his sputum.  On hospital day four,
-the patient was taken to the Operating Room by the Orthopedic
-surgeons for open reduction and internal fixation of his
-humeral fractures; the patient tolerated this procedure well
-without any complications.
-
-Postoperatively, he was transferred back to the Surgical
-Intensive Care Unit where he underwent a prolonged
-ventilatory wean.  The patient was extubated but noted to be
-somewhat confused and initially combative.  The patient was
-thought to be withdrawing from alcohol and was started on
-Ativan drips to control this.  He progressed very well.
-Mental status improved.  He was transferred to the floor.  On
-the floor, he continued to do well with slowly improving
-mental status.  Psychiatry was consulted for care of this and
-recommended a slow Ativan wean and slow Haldol wean.
-
-The patient's antibiotic course was completed.  Follow-up
-chest x-ray revealed resolution of his consolidations and the
-patient's sputum became normal.  He began working with
-Physical Therapy and advanced to a regular diet which he
-tolerated well and will be discharged to rehabilitation.
-
-
-
-                          DR.Tisdale,Adele 02-349
-
-Dictated By:Weston
-MEDQUIST36
+Allergies:
+No Known Allergies / Adverse Drug Reactions
+
+Attending:Griffin
+Chief Complaint:
+Fevers, Altered Mental status
+
+Major Surgical or Invasive Procedure:
+intubated
+
+History of Present Illness:
+Patient unable to give history himself. Most history is from
+Thomas Memorial Hospital. 54M with a history of CABG, remote MI, hip/shoulder
+surgery, liver failure, hypertension, hyperlipidemia,
+depression, alcohol and tobacco abuse who is transferred from
+Williams Medical Center Hospital after decompensating there. The patient is a
+54-year-old man who was brought into Thomas Memorial Hospital from Quahog detox
+with significant juandice, lethargy, and an episode of syncope
+while exiting the bathroom. At Thomas Memorial Hospital, his initial
+presentation was alert and oriented x 3 and speech clear.
+Pertinent labs at Thomas Memorial Hospital: WBC 19.6 Hct 29 Plt 210 INR 2.7
+Lipase 20 K 3.2 Cl 88 Ammonia 66 Ca 7.9 CO2 37 K 3.2 Total bili
+14.7 Direct bili 10.0 Total protein 6.3 Alb 2.6 AST 213 ALT 23.
+The patient then became febrile to nearly 102 and lethragic,
+only oriented to self. He became agitated as well,
+intermittently. At Thomas Memorial Hospital before transfer the patient had
+received 8mg Ativan, 1gm ceftriaxone, 600mg ibuprofen, 40mg K,
+2g IV MG. The patient's urine output began to drop despite 3L
+NS.
+.
+In the ED, temp 98 Hr 120 Bp 123/84 RR 18 94% RA.  Patient was
+given 1mg ativan for sedation, placed in wrist restraints.
+[x] EKG: sinus tachycardia with nonspecific ST-T changes
+[x] CXR:
+[x] RUQ ultrasound was performed.
+[x] Liver consult was called.
+[x] LFTs:
+[x] UA, Ucx:
+[x] Bcx: pending
+[x] Guaiac: Negative
+[x] ICU transfer requested
+[x] Serum, urine tox, tylenol
+[x] SIRS treatment: vancomycin, cefepime, flagyl
+.
+.
+On the floor, was intermittently agitated. BP was 92/52 HR ws 98
+RR was 14 he was 100%on RA.
+.
+Review of sytems:
+could not be obtained as patient is not cooperative
+
+Past Medical History:
+Per OSH history:
+history of CABG
+remote MI,
+hip/shoulder surgery,
+liver failure,
+hypertension,
+hyperlipidemia,
+depression,
+alcohol and tobacco abuse
+
+Social History:
+Tunnel worker. Speaking with sister, he drinks close to a quart
+a day of vodka with gatorade. Rooks last drink. Smokes a pack a
+day. Drugs:Wentzel, but may have in the past. He lives with his
+gilfriend
+
+
+Family History:
+unknown.
+
+Physical Exam:
+VS: T: 97.9, P: 128, BP: 112/53, RR: 26, 91% RA
+General: Oriented to name only.  Intermittently responsive.
+HEENT: Icteric Sclerae, MMM, oropharynx clear
+Neck: supple, JVP not elevated, no LAD
+Lungs: Clear to auscultation bilaterally, no wheezes, rales,
+rhonchi
+CV: tachycardic, normal S1 + S2,
+Chest: multiple spider angiomas throughout.
+Abdomen: tense, +bowel sounds, non-tender, no rebound tenderness
+or guarding, no organomegaly, without shifting dullness,
+tympanitic on percussion.
+GU: foley in place.
+Ext: mild palmar erythema, warm, well perfused, 2+ pulses, no
+clubbing, cyanosis or edema
+Neuro: A&Ox1, Cranial Nerves intact grossly, good strenght in
+his extremities, profound asterixis.
+
+Discharge
+expired
+
+Pertinent Results:
+2143-11-10 09:05PM BLOOD WBC-17.9*# RBC-2.74*# Hgb-10.0*#
+Hct-29.1*# MCV-106*# MCH-36.4* MCHC-34.3 RDW-14.0 Plt Ct-171
+2143-11-10 09:05PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0
+Baso-0 Atyps-0 Metas-0 Myelos-0
+2143-11-10 09:05PM BLOOD PT-23.9* PTT-39.2* INR(PT)-2.3*
+2143-11-10 09:05PM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-137
+K-3.3 Cl-92* HCO3-36* AnGap-12
+2143-11-10 09:05PM BLOOD ALT-24 AST-194* CK(CPK)-65 AlkPhos-261*
+TotBili-14.1* DirBili-9.7* IndBili-4.4
+2143-11-10 09:05PM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.6*
+Mg-1.8 Iron-111
+2143-11-10 09:05PM BLOOD TSH-0.72
+2143-11-11 04:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
+HBcAb-NEGATIVE
+2143-11-11 04:41AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
+2143-11-11 04:41AM BLOOD Dr. Edwards-POSITIVE * Titer-1:40
+2143-11-10 09:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
+Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
+2143-11-11 04:41AM BLOOD HCV Ab-NEGATIVE
+
+discharge
+expired
+
+Brief Hospital Course:
+54M with a history of remote MI, hip/shoulder surgery, liver
+failure, hypertension, hyperlipidemia, depression, alcohol and
+tobacco abuse who is transferred from Williams Medical Center Hospital with
+fevers, leukocytosis and altered mental status, transferred to
+the ICU for hypoxemic respiratory failure. He expired during
+this admission.
+.
+#Hypoxemic Resp. failure- could have been due to mucous
+plugging, pontine demylination. Regardless he was intubated and
+successfully extubated on the 2144-10-1. He tolerated 40% face
+mask and 4-5 L NC. He was re-intubated after transfer to the ICU
+for respiratory distress again later in his course, believed to
+be related to aspiration. He did not recover, family meeting was
+held and he was made CMO, and expired.
+
+
+Medications on Admission:
+n/a
+
+Discharge Medications:
+expired
+
+Discharge Disposition:
+Expired
+
+Discharge Diagnosis:
+expired
+
+Discharge Condition:
+expired
+
+Discharge Instructions:
+expired
+
+Followup Instructions:
+expired
+
+                             Initials (NamePattern4)  Pereira Sandra MD L41590496
 
-D:  2188-1-24  08:52
-T:  2188-1-24  10:40
-JOB#:  Job Number 38197
 "
-"Admission Date:  2126-3-21              Discharge Date:   2126-4-9
+"Admission Date:  2149-11-26              Discharge Date:   2149-11-27
 
-Date of Birth:  2074-3-9             Sex:   M
 
-Service: SURGERY
+Service: MEDICINE
 
 Allergies:
-Patient recorded as having No Known Allergies to Drugs
+Penicillins
 
-Attending:Jaime
+Attending:Rita
 Chief Complaint:
-struck on head by large beam
+Sepsis
 
 Major Surgical or Invasive Procedure:
-anterior cervical fusion 3-21
-posterior cervical fusion 3-24
-Open trach, PEG 3-29
+ERCP/stent placement
 
 History of Present Illness:
-52 year-old male who had a large metal Dr. Tran fall 8 inches onto
-his head. No LOC but on arrival of EMS had no sensation or motor
-function beloow nipples. In field SBP was in 90s started on
-levophed. On arrival there was no sensation/motor function below
-nipple line. The patient was intubated for agitation and started
-on salumedrol drip.
+This is a Age over 90  year old female with hx recent PE/DVT, atrial
+fibrillation, CAD who is transfered from  Allen Clinic Hospital
+for ERCP. She has had multiple admissions to Allen Clinic this
+past month, most recently on 2149-11-20. In early June, she
+presented with back pain and shortness of breath. She was found
+to have bilateral PE's and new afib and started on coumadin. Her
+HCT dropped slightly, requiring blood transfusion, with guaic
+positive stools. She was discharged and returned with abdominal
+cramping and black stools. She was found to have a HCT drop from
+32 to 21. She was given vit K, given a blood transfusion and
+started on protonix. She received an IVF filter and EGD.  EGD
+showed a small gastric and duodenal ulcer (healing), esophageal
+stricture, no active bleeding.  She also had an abdominal CT
+demonstrating a distended gallbladder with gallstones and
+biliary obstruction with several CBD stones. She was started on
+Levo/Flagyl and transfered here for ERCP. Per nursing, her BP
+had been low in 90's at OSH and 80's enroute.
+
+In the ERCP suite, she received vancomycin, Ampicillin and
+Gentamicin as well as Fentanyl. A biliary stent was placed
+successfully in the upper third of the common bile duct. No
+sphincterotomy was done given elevated INR. In addition, a
+single cratered non-bleeding 20mm ulcer was found in the antrum.
 
 
 Past Medical History:
-healthy
+Recent PE/DVT
+Afib
+HTn
+Hypotension
+Hypothyroidism
+CAD
+? mild CHF
 
 Social History:
-married
+lives with daughter and granddaughter, functional at home ,
+non-smoker, no alcohol use
 
 Family History:
-non-contributory
+NC
 
 Physical Exam:
-Awake and alert on arrival.
-10 cm head laceration stapled in the trauma bay.  Pupils are
-equal and reactive.
-Lungs are clear bilaterally.
-Heart is regular.
-Abdomen is soft, nontender, and nondistended.
-Extremities are warm, perfused, but sensation to pin-prick is
-absent over all extremities.  there is no motor function over
-any extremity.
-
+GEN: ill appearing, pale, awake but minimally responsive,
+well-nourished, no acute distress
+HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
+rhinorrhea, MMM, OP Clear
+NECK: No JVD, carotid pulses brisk, no bruits, no cervical
+lymphadenopathy, trachea midline
+COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
+PULM: Lungs CTAB, no W/R/R
+ABD: mildly tender abd diffusely w/o rebound or guarding, ND,
+hypoactive bowelsounds, diff to assess HSM, a soft large
+masses/protuberance in RLQ
+EXT: midly swollen left lower ext, no palpable cords
+NEURO: awake, answering some basic questions but not conversant,
+unable to assess orientation
+SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
 
 Pertinent Results:
-2126-3-21 09:30AM URINE  RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
-EPI-0-2
-2126-3-21 09:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
-GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG
-2126-3-21 09:30AM URINE  COLOR-Yellow APPEAR-Clear SP Cooper-1.026
-2126-3-21 09:30AM   FIBRINOGE-251
-2126-3-21 09:30AM   PT-12.7 PTT-21.4* INR(PT)-1.1
-2126-3-21 09:30AM   PLT COUNT-187
-2126-3-21 09:30AM   WBC-6.7 RBC-4.33* HGB-14.1 HCT-39.1* MCV-90
-MCH-32.7* MCHC-36.1* RDW-13.3
-2126-3-21 09:30AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
-cocaine-NEG amphetmn-NEG mthdone-NEG
-2126-3-21 09:30AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
-bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
-2126-3-21 09:38AM   GLUCOSE-167* LACTATE-1.4 NA+-140 K+-4.3
-CL--106 TCO2-23
-2126-3-21 12:51PM   TYPE-ART PO2-225* PCO2-43 PH-7.29* TOTAL
-CO2-22 BASE XS--5
-2126-3-21 01:11PM   HCT-42.1
-2126-3-21 01:11PM   CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.9
-2126-3-21 01:11PM   GLUCOSE-214* UREA N-21* CREAT-0.9 SODIUM-137
-POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
+Admission Labs:
+2149-11-26 03:15PM   WBC-11.4* RBC-3.61* HGB-11.3* HCT-32.8*
+MCV-91 MCH-31.3 MCHC-34.5 RDW-17.9*
+2149-11-26 03:15PM   NEUTS-76* BANDS-13* LYMPHS-6* MONOS-3 EOS-0
+BASOS-0 ATYPS-0 METAS-2* MYELOS-0
+2149-11-26 03:15PM   HYPOCHROM-NORMAL ANISOCYT-1+
+POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
+POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
+BURR-OCCASIONAL
+2149-11-26 03:15PM   PLT SMR-NORMAL PLT COUNT-166
+2149-11-26 03:15PM   PT-25.8* PTT-39.2* INR(PT)-2.5*
+2149-11-26 06:12PM   ALT(SGPT)-56* AST(SGOT)-68* LD(LDH)-357* ALK
+PHOS-100 TOT BILI-1.3
+2149-11-26 06:12PM   GLUCOSE-128* UREA N-85* CREAT-2.8* SODIUM-139
+POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-16* ANION GAP-17
+
+Other important labs:
+2149-11-27 03:35AM BLOOD WBC-14.8* RBC-3.15* Hgb-10.0* Hct-28.9*
+MCV-92 MCH-31.9 MCHC-34.8 RDW-17.8* Plt Ct-162
+2149-11-27 03:35AM BLOOD Glucose-81 UreaN-85* Creat-3.0* Na-138
+K-4.4 Cl-107 HCO3-15* AnGap-20
+2149-11-27 03:35AM BLOOD ALT-50* AST-63* AlkPhos-87
+2149-11-27 03:35AM BLOOD Calcium-7.5* Phos-4.8* Mg-1.8
+2149-11-27 10:14AM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-101
+pCO2-13* pH-7.20* calTCO2-5* Base XS--20 Intubat-NOT INTUBA
+2149-11-27 10:14AM BLOOD Lactate-10.5*
+
+KUB: Supine film shows gas-filled loops of large and small bowel
+with gas in the region of the rectum. The appearances are
+inconsistent with obstruction and do not suggest ileus
+
+CXR: no failure
+
+RUQ ultrasound: report pending at time of death
 
 Brief Hospital Course:
-Mr. Adam was evaluated in the Trauma Bay and a spine
-consult was obtained immediately.
-
-His injuries included:
-C4-6,2-1 fractures, nonenhancing vertebral artery R C3-6, R 1st
-rib, R clavicle, scalp lac, cervical epidural hematoma no
-motor/senstn UEs or Esther
-Zuniga/CTA Hd: no acute bleed
-CT/CTA Csp: as above
-CT Torso: as above
-
-The steroid protocol was initiated and continued for a total of
-24 hours.  He was brought to the operating room for an anterior
-cervical fusion (3-21).  The patient was stabilized and returned
-to the OR for a posterior fusion (3-24).
-
-An IVC filter was placed by the Vascular surgery service.
-
-After the spine surgery team cleared the patient, an open
-tracheostomy and percutaneous endoscopic gastrostomy tube were
-performed (3-29).
-
-His postoperative course has been complicated by a postoperative
-pneumonia.  He was treated with a 7 day course of levofloxacin
-for a pan sensitive enterobacter pneumonia (3-27).  At present
-he has MRSA (4-1, 4-2) growing from sputum and has been treated
-now with 8 days of vancomycin.  He also has been started on
-pipercillin-tazobactam (4-8) for gram negative rods in his
-sputum (4-2).
+Septic from the time of transfer from the OSH for ERCP. Required
+blood pressure support with levophed, which was changed to
+neosynephrine due to elevated HR.  Difficult to volume
+resuscitate given developement of crackles/increasing O2
+requirement with fluid.  Treated with vanc/cipro/flagyl and
+changed to meropenem/vanc. Had stent done by ERCP, but
+sphincterotomy/stone removal not done due to elevated INR.  Most
+likely source of sepsis is biliary/ascending cholangitis.
+Evaluated by General surgery team, who thought she was not a
+surgical candidate and would not recommend IR cholecystostomy
+tube. Lactate rose to 10.5, last ABG 7.2/13/101.  The patient
+complained of significant pain, difficult to control with bolus
+morphine.  Bedside ultrasound was being done to evaluate for
+cholecystitis when the family decided to make the patient CMO
+and the study was stopped. Preliminary report not available at
+the time of death.  The patient was made CMO by her family and
+expired comfortably on a morphine gtt at 16:20 on 2149-11-27.
+Medical examiner declined the case, family declined autopsy.
 
 Medications on Admission:
-none
+ASA 325mg
+Lopressor 25mg Patrick Clinic
+Amiodarone 200mg Patrick Clinic
+Coumadin 2.5mg daily
+Isosorbide 60mg daily
+Levothyroixine 50mcg daily
 
 Discharge Medications:
-1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
-Q4H (every 4 hours) as needed.
-2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
-HS (at bedtime) as needed.
-3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
-times a day).
-4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
-PO DAILY (Daily).
-5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
-(every 4 to 6 hours) as needed for fever.
-6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
-Injection TID (3 times a day).
-7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
-(2 times a day).
-8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
-HS (at bedtime) as needed.
-9. Therapeutic Multivitamin     Liquid Sig: Five (5) ML PO Q 24H
-(Every 24 Hours).
-10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1)  PO DAILY
-(Daily).
-11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-
-12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
-Miscell.  Q2H (every 2 hours) as needed.
-13. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One
-(1)  PO DAILY (Daily).
-14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H
-(Every 3 to 4 Hours) as needed.
-15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
-hours) as needed for mucous production.
-16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
-needed.
-17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
-(4 times a day) as needed.
-18. Metoclopramide 5 mg/mL Solution Sig: One (1)  Injection Q6H
-(every 6 hours).
-19. Lorazepam 2 mg/mL Syringe Sig: 12-31  Injection Q2H PRN () as
-needed for anxiety.
-20. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
-Intravenous  Q 8H (Every 8 Hours).
-21. Ampicillin-Sulbactam 1-30 g Recon Soln Sig: Three (3) Recon
-Soln Injection Q8H (every 8 hours).
-22. Acetazolamide Sodium 500 mg Recon Soln Sig: One (1) Recon
-Soln Injection Q6H (every 6 hours).
-
+expired
 
 Discharge Disposition:
-Extended Care
-
-Facility:
-True Corporation
+Expired
 
 Discharge Diagnosis:
-C4-6, T2-3 fractures with quadraplegia
-
+Septic shock due to ascending cholangitis
+Choledocholithiasis
+Atrial fibrillation with rapid ventricular response
+Pulmonary emboli
+Deep venous thrombosis
+Upper GI bleed
+Peptic ulcer disease
 
 Discharge Condition:
-stable
-
+expired
 
 Discharge Instructions:
-tracheostomy care
-gastrostomy care
+expired
 
+Followup Instructions:
+expired
 
 
 "
-"Admission Date: 2126-10-24        Discharge Date: 2126-10-30
+"Admission Date:  2182-2-23              Discharge Date:   2182-2-28
 
-Date of Birth:  2063-1-14        Sex:  M
 
-Service:  CSU
+Service: SURGERY
 
+Allergies:
+Patient recorded as having No Known Allergies to Drugs
 
-HISTORY OF PRESENT ILLNESS:  This is a 63 year old gentleman
-who has a prior history of myocardial infarction in 2122-2-17 who underwent stent to his left anterior descending and
-right coronary artery at the time with subsequent multiple
-episodes of instant restenosis, requiring brachytherapy.  The
-patient underwent a routine stress test, which showed
-reversible anterior ischemia and was referred to Shaw Medical Center for cardiac catheterization.
+Attending:Drew
+Chief Complaint:
+Abdominal pain
 
-PAST MEDICAL HISTORY:  Hypercholesterolemia.  Status post
-myocardial infarction.  Status post multiple PCI.
-Hypertension. Status post removal of colonic polyps.  Status
-post appendectomy.  Status post removal of lipoma.  Status
-post removal of precancerous lesion from his back.
+Major Surgical or Invasive Procedure:
+ERCP 2182-2-24
 
-ALLERGIES:  No known drug allergies.
+History of Present Illness:
+This patient is a 84 year old woman who initially presented to
+Jamison Medical Center hospital with 3 day history of abdominal pain. She was
+found to have gallstone pancreatitis and received Levo/flagyl.
+She was subsequently transferred to the Ruiz Memorial Hospital. She has had known
+gallstones for the last 30-40 year without symptoms.
+.
+At Ruiz Memorial Hospital, the patient reported epigastric pain radiating to
+back, nausea, vomiting, chills but no fever. She denied chest
+pain and shortness of breath. She denied jaundice. She had one
+bowel movement on the day prior to presentation.
+
+Past Medical History:
+PMH:  CAD/MI, HTN, h/o gallstones (no prior symptoms), ""blood
+poisoning"" resulting in trach, breast cancer
+PSH:  CABGx4 '67, appy, hysterectomy, trach, lumpectomy/XRT, B/L
+cataracts
 
-PREOPERATIVE MEDICATIONS:
-1. Accupril 40 mg p.o. q. Day.
-2. Hydrochlorothiazide 25 mg p.o. q. Day.
-3. Toprol XL 50 mg p.o. twice a day.
-4. Verapamil SA 240 mg p.o. q. Day.
-5. Aspirin 325 mg p.o. q. Day.
-6. Plavix 75 mg p.o. q. Day.
-7. Lipitor 40 mg p.o. q. Day.
-8. Folic acid 1 mg p.o. twice a day.
-9. Tums.
-10.      Multi-vitamin supplements.
-
-
-HOSPITAL COURSE:  The patient was admitted to Shaw Medical Center on 2126-10-24 and underwent
-cardiac catheterization which showed left ventricular end
-diastolic pressure of 17, which rose to 22 after the LV gram;
-ejection fraction of 50 percent; 90 percent left main lesion
-and patent stents in the left anterior descending, left
-circumflex and right coronary artery.  The patient was
-referred to cardiac surgery for operative management.  The
-patient was taken to the operating room on 2126-10-25
-with Dr. Soule for coronary artery bypass graft times two;
-left internal mammary artery to left anterior descending and
-saphenous vein graft to ramus.  Total cardiopulmonary bypass
-time was 61 minutes; cross clamp time 44 minutes.  The
-patient was transferred to the Intensive Care Unit in stable
-condition.  The patient was weaned and extubated from
-mechanical ventilation on his first postoperative evening.
-On postoperative day number one, the patient was transferred
-from the Intensive Care Unit to the regular part of the
-hospital.  The patient began ambulating with physical
-therapy. The patient was started on low dose Lopressor.  On
-postoperative day number two, the patient's chest tubes and
-pacing wires were removed without incident.
-
-On postoperative day number three, the patient complained of
-seeing flashing lights when he was trying to read.  He had no
-history of this sensation prior.  An ophthalmology consult
-was obtained. It was determined that the patient's blood
-vessels in his eyes were normal.  He had a posterior vitreous
-detachment in the left eye which required no intervention and
-was probably an old finding.  They recommended that the
-patient follow-up as needed.  The patient was restarted on
-ace inhibitor for hypertension control.  By postoperative day
-number four, the patient was able to ambulate 500 feet and
-climb one flight of stairs with physical therapy.  ON
-postoperative day number five, the patient was cleared for
-discharge to home.
-
-CONDITION ON DISCHARGE:  Temperature maximum of 100.3; pulse
-87 and sinus rhythm; blood pressure 140/90; respiratory rate
-16; oxygen saturation 95 percent on room air.  The patient's
-weight was 95.5 kg.  Neurologically, the patient was awake,
-alert and oriented times three.  Cardiovascular:  Regular
-rate and rhythm without murmur or rub.  Respiratory breath
-sounds are decreased at bilateral bases without rhonchi,
-wheezes or rales.  Abdomen:  Soft, nondistended, nontender.
-Sternal incision was clean, dry and intact.  Sternum is
-stable.  Right lower extremity vein harvest site with
-significant ecchymosis in the right thigh, mildly tender to
-palpation.  No apparent hematoma.  The incision was clean,
-dry and intact.
-
-LABORATORY DATA:  White blood cell count of 10.9; hematocrit
-of 28.3; platelet count of 316.  Sodium of 140; potassium of
-3.8; chloride 107; bicarbonate of 24; BUN 14; creatinine 0.7;
-glucose 139.
-
-DISPOSITION:  The patient was discharged home in stable
-condition.
-
-DISCHARGE DIAGNOSES:  Coronary artery disease.
-
-Status post coronary artery bypass graft.
-
-Hypertension.
+Social History:
+Quit tobacco 30 years ago
+Rarely drinks EtOH
 
-DISCHARGE MEDICATIONS:
-1. Lasix 20 mg p.o. q. Day times 7 days.
-2. Potassium chloride 20 mEq p.o. q. Day times 7 days.
-3. Colace 100 mg p.o. twice a day.
-4. Zantac 150 mg p.o. twice a day.
-5. Aspirin 325 mg p.o. q. Day.
-6. Plavix 75 mg p.o. q. Day.
-7. Lipitor 40 mg p.o. q. Day.
-8. Dilaudid 2 mg tablets, one p.o. every four to six hours
-   prn.
-9. Accupril 40 mg p.o. q. Day.
-10.      Toprol XL 150 mg p.o. q. Day.
+Physical Exam:
+102.2 76 97/34 22 93% 3l
+NAD, alert and oriented x 3
+neck supple
+CTAB
+RRR
+abdomen mildly distended, tender to percussion/palpation in
+epigastrium, +Dr. Reynolds with guarding
+rectal tone normal, negative guiac at French
+Foley with clear urine
+RLE edema (chronic)
 
-The patient is to be discharged home in stable condition. He
-is to follow-up with his primary care physician, Baker. Soule,
-in one to two weeks.  He is to follow-up with his
-cardiologist, Dr. Soule, in two to three weeks. He is to follow-
-up with Dr. Soule in three to four weeks.
+Pertinent Results:
+ERCP 2182-2-24: Dilated CBD and PD, Multiple CBD stones and
+biliary pus, Biliary sphincterotomy, Stone extraction, CBD stent
+
+2182-2-23 10:50PM   WBC-9.0 RBC-3.35* HGB-10.6* HCT-30.0* MCV-90
+MCH-31.7 MCHC-35.3* RDW-13.7
+2182-2-23 10:50PM   PLT COUNT-159
+2182-2-23 10:50PM   NEUTS-90.8* BANDS-0 LYMPHS-6.1* MONOS-2.8
+EOS-0.2 BASOS-0.1
+2182-2-23 10:50PM   GLUCOSE-140* UREA N-25* CREAT-1.1 SODIUM-137
+POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13
+2182-2-23 10:50PM   ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-2.0*
+MAGNESIUM-1.6
+
+2182-2-23 10:50PM   ALT(SGPT)-568* AST(SGOT)-537* CK(CPK)-66 ALK
+PHOS-581* AMYLASE-553* TOT BILI-2.9*
+
+Brief Hospital Course:
+This patient was admitted to the SICU with cholangitis,
+pancreatitis and cholecystitis. In the ED, the patient
+experienced respiratory distress and was intubated. ERCP was
+perfomed at the bedside at which time the findings included:
+Dilated CBD and PD, Multiple CBD stones and biliary pus, Biliary
+sphincterotomy, Stone extraction, CBD stent. In the unit, the
+patient was started on Zosyn, and was supported briefly with
+Levophed. On hospital day #2, the patient was successfully
+extubated. On hospital day #3, she was transferred to the floor.
+Her antibiotics were changed from IV Zosyn to PO
+Levaquin/Flagyl. Her diet was advanced gradually which she
+tolerated well. On hospital day #5 she was cleared by physical
+therapy for discharge to home with services. She was discharged
+in stable condition on hospital day #6. She will continue PO
+Levaquin/Flagyl for 4 days at home and will follow up with Dr.
+Bird in 12-31 weeks for cholecystectomy.
 
 
+Medications on Admission:
+Sherwood:  toprol XL 25QD; ASA 325QD; enalapril 10QD; lipitor 5QD;
+fluoxetine prn; xanax 0.5prn; MVI; slo niacin 500QD
+
+Discharge Medications:
+1. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
+(Daily) for 1 months.
+Disp:*30 Tablet(s)* Refills:*0*
+2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
+times a day) for 4 days.
+Disp:*12 Tablet(s)* Refills:*0*
+3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
+24 hours) for 4 days.
+Disp:*4 Tablet(s)* Refills:*0*
+
 
+Discharge Disposition:
+Home
 
+Discharge Diagnosis:
+Cholangitis
+Pancreatitis
+Cholecystitis
 
+Discharge Condition:
+Stable, tolerating po
+
+Discharge Instructions:
+worsening abdominal pain, signs of jaundice or any other
+worrisome symptoms.
+
+Please follow-up as directed.
+
+Please resume all medications as taken prior to this
+hospitalization. In addition, you should take the antibiotics
+and iron tablets as prescribed.
+
+Maintain a low fat diet. For additional nutritional support we
+recomment nutritional supplements such as Boost, Ensure, or
+Resource at breakfast, lunch, and dinner.
+
+Continue antibiotics.
+
+
+Followup Instructions:
+Provider: Roszel. Kenneth Initial (NamePattern1)  Roszel Phone:942-852-2246
+Date/Time:2182-4-11 9:30
+Provider: William SUITE GI ROOMS Date/Time:2182-4-11 9:30
+
+Follow-up with Dr. Bird in 12-31 weeks.  Call her office at
+484-466-8077 to schedule your appointment.
 
 
-                        Jacqueline Marcos, M.D. G57933924
 
-Dictated By:Halsey
-MEDQUIST36
-D:  2126-10-30 18:05:44
-T:  2126-10-30 21:26:14
-Job#:  Job Number 31718
 "
-"Admission Date: 2176-9-25        Discharge Date: 2176-10-4
-
-Date of Birth:                    Sex:  M
-
-Service:  General Surgery
-
-
-DIAGNOSES:
-1. Mesenteric venous thrombosis with bowel ischemia and
-   infarction.
-2. Congestive heart failure.
-3. Respiratory failure.
-4. Sepsis.
-5. Tetralogy of Fallot.
-6. Down syndrome.
-7. Paget disease.
-8. Chronic conjunctivitis.
-9. Seizure disorder.
-10.      Peripheral vascular disease.
-
-
-CHIEF COMPLAINT:  Respiratory failure with mesenteric
-thrombosis.
-
-HISTORY OF PRESENT ILLNESS:  The patient is a 37-year-old
-gentleman with Down syndrome and tetralogy of Fallot who
-presented to Poe Memorial Hospital Hospital from his group care facility
-on 2176-9-22, with complaints of diarrhea, nausea, vomiting
-and acute abdominal pain x 48 hours.  He was initially
-admitted to the medical floor but acutely desaturated and
-went into respiratory failure.  He required intubation and
-was transferred to the ICU.  He had bilateral pulmonary
-infiltrates.  He was started empirically on intravenous
-antibiotics and began spiking temperatures and his abdominal
-pain worsened.  He started passing bright red blood per
-rectum and a CT scan was performed, which demonstrated
-mesenteric venous thrombosis.  He had a hematocrit drop from
-43 to 29 and he was transfused for supportive therapy.  His
-respiratory status deteriorated and he was transferred to the
-West Memorial Hospital for further tertiary
-care on 2176-9-25.
+"Admission Date:  2115-5-30     Discharge Date:  2115-6-4
+
+Date of Birth:   2061-3-22     Sex:  F
+
+Service:
+
+ADMISSION DIAGNOSIS:  Breast cancer.
+
+DISCHARGE DIAGNOSES:
+1. Breast cancer.
+2. Status post Cranford on the right, mastectomy.
+
+HISTORY OF PRESENT ILLNESS:  The patient is a 54-year-old
+woman who had a recent diagnosis of right breast cancer.
+Core biopsy returned as invasive carcinoma.  The patient had
+a lumpectomy and sentinel node biopsy which were negative but
+with positive margins.  Patient went back for re-excision and
+again had positive margins.  The patient is now consulted for
+a right mastectomy with Cranford, free flap reconstruction.  The
+patient understands all surgical alternatives, and has agreed
+to this decision.
 
 PAST MEDICAL HISTORY:
-1. Down syndrome.
-2. Congenital heart disease.
-3. Tetralogy of Fallot.
-4. Paget disease.
-5. Chronic conjunctivitis.
-6. Seizure disorder.
-7. Mental retardation.
-8. Depression.
-9. Peripheral vascular disease.
-
-
-PAST SURGICAL HISTORY:  None could be elicited, as the
-patient was not responsive.
-
-MEDICATIONS ON ADMISSION:
-1. Dilantin.
-2. Ativan.
-3. Colace.
-4. Aspirin.
-5. Valium.
-6. Multivitamin.
-7. Bacitracin.
-8. Lasix.
-9. Digoxin.
-10.Claritin.
-11.Tinactin.
-12.Penicillin.
-13.Zoloft.
-14.Protonix.
-15.Vancomycin.
-
-
-ALLERGIES:  GENTAMICIN EYE DROPS causing rash.
-
-SOCIAL HISTORY:  He lives in a group home and he is
-profoundly retarded and nonambulatory, nonverbal and
-frequently combative.  He does not drink or smoke.
-
-PHYSICAL EXAMINATION:  His temperature is 101.8, heart rate
-88, blood pressure 104/54, he is saturating 96 percent on
-assist  control with 100 percent FiO2.  Generally, he was
-sedated, intubated and nonresponsive.  His head was
-normocephalic.  His mucous membranes were dry and he had
-nasogastric tube and an endotracheal tube.  Reflexes could
-not be elicited.  His chest had coarse breath sounds
-bilaterally with diminishment at the bases.  He was without
-wheezes or crackles.  His heart was regular rate and rhythm
-with a 4/6 systolic murmur.  His abdomen was distended and
-soft.  He had no bowel sounds.  He had anasarca with pitting
-edema in both extremities.  His white blood cell count was
-11.2.  His hematocrit 32, his platelet count 159, 87
-neutrophils, no bands, 9 lymphocytes.  Sodium was 150,
-potassium was 3.8, chloride was 114, bicarbonate 27, BUN 23,
-creatinine 0.9 and glucose 96.  His calcium was 8.1,
-magnesium was 1.8, phosphorus was 2.2.  AST 44, ALT 20,
-alkaline phosphatase 77, amylase 73, lipase 13, albumin 2.1,
-and total bilirubin 0.4.  Blood cultures were taken and a
-urine culture was taken.  His PT was 16.8 and INR 1.8.  His
-ABG was pH 7.33, pO2 of 136 and pCO2 of 60.  Lactate of 1.
-
-Chest x-ray showed bilateral fluffy infiltrates about
-pneumoperitoneum.
-
-CT scan was reviewed from the outside hospital and
-demonstrated mesenteric venous thrombosis with bowel wall
-thickening and ascites.
-
-CONCISE SUMMARY OF HOSPITAL COURSE:  The patient was admitted
-on 2176-9-25, started on intravenous heparin and broad-
-spectrum antibiotics.  His condition initially improved and
-then did plateau.  A central line was placed for access for
-parenteral nutrition and he was started on parenteral
-nutrition.  The patient continued to have heme-positive stool
-and his hemodynamics secondary to his tetralogy of Fallot and
-his ischemia did not improve.  Cardiology consult, Vascular
-consult and Infectious Disease consult were all obtained.
-The patient's condition stabilized but did not significantly
-improve over the course of approximately 1 week.  After
-detailed discussions with the patient's family, it was
-decided that no surgery would be performed in the event that
-the bowel declared itself as being infarcted rather than
-merely ischemic.  The patient was transferred to the Medical
-Service for supportive therapy.  The patient continued with
-lack of improvement and the Balmora Organ Bank was
-contactJames and the patient was chosen for donation.  On
-2176-10-4, the patient was taken to the operating room.  He
-was extubated and declared dead and his organs were
-harvested.
-
-
-DATE OF DEATH:  2176-10-4.
-
-
-
-                        Judy Filler, T42279639
-
-Dictated By:Gomez
-MEDQUIST36
-D:  2176-12-17 14:47:01
-T:  2176-12-17 23:06:56
-Job#:  Job Number 50984
+1. Mitral valve prolapse.
+2. Status post C section.
+3. Status post right breast biopsy.
+4. Status post right lumpectomy with sentinel node.
+
+ALLERGIES:  Penicillin and sulfa.
 
+MEDICATIONS:
+1. Vitamins.
+2. Calcium.
+3. Antioxidant.
 
+PHYSICAL EXAMINATION ON ADMISSION:  Vital signs stable,
+afebrile.  General:  Is in no acute distress.  Chest was
+clear to auscultation bilaterally.  Cardiovascular is
+regular, rate, and rhythm without murmurs, rubs, or gallops.
+Abdomen is soft, nontender, nondistended with no masses or
+organomegaly.  Extremities are warm, noncyanotic,
+nonedematous x4.  Neurologic is grossly intact.
 
+HOSPITAL COURSE:  The patient was admitted for semielective
+mastectomy with Cranford on the right reconstruction.  The
+patient was taken to the operating room on 2115-5-30, and had
+the procedure performed as outlined above.  The patient
+tolerated the procedure well without complication in the
+postoperative course, she was immediately placed in the
+Intensive Care Unit for close monitoring.  The patient had
+flap checks per protocol q 30 minutes for the first 12 to 24
+hours followed by q1 hour followed by q2 hour checks.  The
+flap seemed to be doing well, and a Doppler probe was left
+close to the venous outflow postoperatively.  Flap was seen
+to be doing very well, and the patient was transferred to the
+floor on postoperative day #3.  Subsequent to this, the
+patient had an unremarkable hospital stay, and the Doppler
+probe was removed on postoperative day #4, the patient
+subsequently discharged to home.
 
+DISCHARGE CONDITION:  Good.
+
+DISPOSITION:  Home.
+
+DIET:  Adlib.
+
+MEDICATIONS:  Resume all home medications.
+1. Magnesium hydroxide.
+2. Milk of magnesia prn.
+3. Percocet 5/325 1-24 q4-6h prn.
+4. Colace 100 mg Malone Clinic.
+5. Clindamycin 300 mg q6 x7 days.
+6. Enteric coated aspirin 81 mg q day.
+
+DISCHARGE INSTRUCTIONS:  The patient is to followup with Dr.
+Diana in his clinic within one week.  No heavy lifting.
+Patient should return if any problems with either incision
+sites or any signs of cellulitis or infection.
+
+
+
+
+                          Joanne Elizondo, M.D.  R87779244
+
+Dictated By:George
+
+MEDQUIST36
+
+D:  2115-6-3  09:28
+T:  2115-6-3  11:56
+JOB#:  Job Number 49686
 "
-"Admission Date:  2195-10-19              Discharge Date:   2195-10-19
+"Admission Date:  2115-2-9              Discharge Date:   2115-2-10
 
-Date of Birth:  2156-3-29             Sex:   M
+Date of Birth:  2075-6-15             Sex:   F
 
 Service: MEDICINE
 
 Allergies:
-Fish Protein / Shellfish Derived
+Shellfish
 
-Attending:Alexis
+Attending:Wendy
 Chief Complaint:
-multi-organ failure
+DKA
 
 Major Surgical or Invasive Procedure:
-none
+None
 
 History of Present Illness:
-The patient is a 45 y.o. man with pmh significant for
-hypertension and obstructive sleep apnea, who presented to an
-outside hospital with abdominal pain, shortness of breath,
-nausea and vomiting, chest pain, and hematuria. His wife reports
-his symptoms began friday when he noticed hematuria. he
-presented to the OSH ED, where CT abdomen was unrevealing and he
-was told he passed a kidney stone. He went home, where he
-developed abdominal pain. His pain was crampy in nature, and
-localized over the left lower quadrant. He then developed lower
-back pain and shortness of breath, with profound dyspnea on
-exertion. Sunday night his abdominal pain was increasing in
-severity. He then presented to the Plymel Medical Center ED
-Monday Morning. At presentation he had an INR of 4.0, other labs
-consistent with DIC, hypotension with systolic blood pressure in
-the 60's and oxygen saturation in the 70's. He was reporting
-epigastric tenderness. Liver enzymes were also elevated, with T
-bili 8.8, Direct Bili 5.5, AST 13,000, ALT 7820, LDH 11,000.
-BUN/Cr 20/3.5. He was intubated, given ceftriaxone, levaquin,
-and flagyl, and 1L NS, and transferred to Hadley Hospital. On arrival here
-he was still hypotensive. A right IJ line was placed. A femoral
-arterial line was placed as well. levophed was added and his
-blood pressure was 66/34. he was given 5 Liters of NS.
-vancomycin and zosyn were added. Initial labs in ED showed pH
-6.90/76/86/16, lactate of 14.0.
-.
-On presentation to the ICU he underwent TEE which revealed
-hypertrophic obstructive cardiomyopathy, but no aortic
-dissection. The patient became asystolic during this procedure
-and was coded, receiving CPR, epinephrine, CaCl2, HCO3. .
-.
-He was placed on levophed, vasopressin, neosynephrine. He
-received 3 more liters of 150meq sodium HCO3, and is receiving
-continuous 150meq NaHCO3.
+39 y/o female with T1DM who presents with weakness and was found
+to be hyperglycemic. Pt reports that she had been feeling weak
+over the past 1-2 days and did not take her insulin for two
+days. Denies F/C. Denies CP or SOB. Denies urinary or bowel
+symptoms. Does admit to N/V. Denies hematemesis, melena, or
+hematochezia. Admits to mild URI symptoms over the past 2 days.
+
+
+In the ED, vitals upon presentation were T 98.6 HR 123 BP 132/69
+RR 19 99%RA. Laboratory testing revealed DKA and she was given a
+bolus of 10 units of regular insulin and started on an insulin
+gtt. She was also aggressively fluid resuscitated with IVF, a
+total of 4L NS. Her FSBG improved to ~240 and she was started on
+D51/2NS. Her symptoms improved dramaticallly. She was also given
+potassium and zofran. CXR was WNL. She was admitted to the ICU
+for further care.
 
 
 Past Medical History:
-Hypertension
-Sleep apnea
+Type I Diabetes Mellitus with mild retinopathy, las A1C 10%
 
 
 Social History:
- drinks one pint of rum or vodka daily, last drink was 4 days
-ago.
-No cigarettes or tobacco.
-No illicit drug use.
+Former tobacco, quit 9 years ago. Rare EtOH. No IVDU, lives with
+two children. ETOH socially. Works at Rubalcava Clinic as practive
+manager.
 
 
 Family History:
-Mother and father with Diabetes.
+Grandmother had diabetes and leukemia.  Mother has benign breast
+disease.  Son recently diagnosed with DM type I.
 
 Physical Exam:
-Vitals: T: BP:115/39 P:115 R:25 O2: 91% on FiO2 100%, TV 600,
-PEEP 15, PIP 40.
-General: intubated, sedated. obese
-HEENT: Sclera anicteric
-Neck: obese, difficult to assess.
-Lungs: diffuse rhonchi bilaterally
-CV: tachycardic, regular, no m/g/r
-Abdomen: obese. NT
-Ext: poor capillary refill. no edema.
+On Presentation:
+
+VSS
+GEN: NAD.
+HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
+rhinorrhea, MMM, OP Clear.
+NECK: No JVD, carotid pulses brisk, no bruits, no cervical
+lymphadenopathy, trachea midline.
+COR: RRR, no M/G/R, normal S1 S2, radial pulses +2.
+PULM: Lungs CTAB, no W/R/R.
+ABD: Soft, NT, ND, +BS, no HSM, no masses.
+EXT: No C/C/E, no palpable cords.
+NEURO: alert, oriented to person, place, and time. CN II ?????? XII
+grossly intact. Moves all 4 extremities. Strength 5/5 in upper
+and lower extremities. Patellar DTR +1. Plantar reflex
+downgoing. No gait disturbance. No cerebellar dysfunction.
+SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
 
 
 Pertinent Results:
-2195-10-19 02:30PM   FIBRINOGE-96.6*
-2195-10-19 02:30PM   PLT COUNT-131*
-2195-10-19 02:30PM   PT-60.9* PTT-86.4* INR(PT)-6.9*
-2195-10-19 02:30PM   WBC-17.4* RBC-4.54* HGB-13.9* HCT-44.5 MCV-98
-MCH-30.5 MCHC-31.1 RDW-14.0
-2195-10-19 02:30PM   NEUTS-93.6* LYMPHS-4.6* MONOS-1.2* EOS-0.2
-BASOS-0.3
-2195-10-19 02:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-34.5*
-bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
-2195-10-19 02:30PM   CORTISOL-46.4*
-2195-10-19 02:30PM   D-DIMER->68341
-2195-10-19 02:30PM   HAPTOGLOB-20*
-2195-10-19 02:30PM   ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-11.3*
-MAGNESIUM-2.4
-2195-10-19 02:30PM   LIPASE-66*
-2195-10-19 02:30PM   ALT(SGPT)-6680* AST(SGOT)-19417* CK(CPK)-452*
-ALK PHOS-144* TOT BILI-8.0* DIR BILI-5.5* INDIR BIL-2.5
-2195-10-19 03:25PM   O2 SAT-89
-2195-10-19 03:25PM   LACTATE-13.2*
-
-Micro:
-2195-10-19 BLOOD CULTURE Blood Culture, Routine-PENDING
-EMERGENCY Perez Clinic
-2195-10-19 BLOOD CULTURE Blood Culture, Routine-PENDING
-EMERGENCY Perez Clinic
-
-Imaging:
-CT abd/pelvis:
-1. Left lower lobe consolidation consistent with pneumonia. In
-this location, aspiration is a potential etiology.
-2. Fatty liver.
-3. Air and decompressed urinary bladder consistent with
-instrumentation,
-correlate clinically.
-
-CXR:
-support lines remain in place; OGT not completely visualized.
-allowing for
-portable supine technique and low lung volumes, heart size may
-not be
-enlarged. left lower lobe consolidation and ill-defined right
-perihilar
-opacity are as seen on earlier same day CXR and CT abd/pelv.
-areas of
-consolidation in RUL and LUL somewhat more confluent. no supine
-evidence of large ptx or large effusion seen. rt lateral sulcus
-excluded.
-
-TEE:
-LVEF 75%, no evidence of aortic dissection
-
+CXR: No acute process
 
 Brief Hospital Course:
-45 year old man with pmh significant for obstructive sleep
-apnea, hypertension, presenting with profound lactic acidosis
-and hypotension despite three vasopressors.
-.
-#Hypotension: Differential included septic shock, vs. mesenteric
-ischemia. Aortic dissection was not found on TEE. CT abdomen was
-significant only for mild retroperitoneal fat stranding.
-Babesiosis is a possibility given residence on Olympus. Other infectious sources include cholangitis or
-cholecystitis given elevated liver enzymes.  Patient was
-administered broad spectrum antibiotics-vanc, zosyn, flagyl,
-doxycycline. He was maintained on vasopressin, phenylephrine,
-dopamine, and levophed for pressor support. He was given NaHCO3,
-LR for fluids. Patient expired before RUQ ultrasound could be
-done.
+39 y/o female with T1DM who presents with weakness and was found
+to be hyperglycemic and in DKA, resolved with insulin gtt,
+fluids and electrolytes.  Discharged home in stable condition on
+home insulin regimen.
 
-.
-# Lactic Acidosis: Differential included sepsis and mesenteric
-ischemia given history of abdominal cramping pain.  He was
-maintained on broad spectrum antibiotic. He was not a surgical
-candidate in light of his other comorbidities.
+# DKA - Unclear precipitant, patients with vague URI and
+abdominal complaints though no diarrhea. Anion gap in 30's on
+admission with kentones in urine. FAggressively fluid
+recussitated with electrolyte repletion with subsequent closeure
+of anion gap to 10. Initially treated with insulin gtt and
+transitioned to home dose of Levemir 35 untis qday and home
+sliding scale. Cultures negative
 
-.
-# Transaminitis: Likely shock liver in setting of reported
-hypotension at OSH. Must also consider other liver etiologies,
-including acetaminophen, alcoholic hepatitis (given EtOH
-history). Serum and urine tox were sent.  He did have an
-elevated acetaminophen level, which could have contributed to
-fulminant hepatic failure especially in light of heavy ETOH use.
-
-.
-# DIC:  Patient was supported with FFP, cryoprecipitate, and
-vitamin K.
+# Ppx:  Received heparin products.
 
-# Myocardial infarction: Patient had ST elevations in V1 through
-V4, likely secondary to demand ischemia in light of severe
-hypotension.
+# Code: full code
 
-Patient expired at 20:35 on 2195-10-19. His wife requested autopsy
-to determine cause of death.
 
 Medications on Admission:
-amlodipine
-celexa
-lisinopril
+Zocor 40 mg daily
+Novalog Insulin
+Levemir Insulin
+Flonase PRN
+Aspirin 81 mg daily (although probably only takes 1-2x a week
+because she forgets to take it)
 
 
 Discharge Medications:
-Patient expired
+1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
+(Daily).
+2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
+PO DAILY (Daily).
+3. Insulin Detemir 100 unit/mL Solution Sig: Thirty Five (35)
+units Subcutaneous once a day.
+4. Insulin Aspart 100 unit/mL Solution Sig: One (1) unit
+Subcutaneous four times a day: Please take per your sliding
+scale.
+5. Flonase 50 mcg/Actuation Spray, Suspension Sig: 1-2 puffs
+Nasal twice a day as needed for shortness of breath or wheezing.
+
+
 
 Discharge Disposition:
-Expired
+Home
 
 Discharge Diagnosis:
-pt expired
+Diabetic Ketoacidosis
+
 
 Discharge Condition:
-pt expired
+Stable, Afebrile
+
 
 Discharge Instructions:
-pt expired
+You were admitted to the hospital for your very high blood sugar
+and diabetic ketoacidosis, it is likely you got this as you were
+not able to take your insulin. Whilst in the hospital you were
+started on diabetes medication and your blood sugars were
+monitored carefully. Prior to discharge your labs showed your
+diabetic ketoacidosis had resolved.
+
+We made no changes to your insulin regimen, please take it as
+prescribed. Please continue taking a diabetic diet.
+
+Please call Miller Diabetes Centre at 216-684-4607 within the
+next 2 weeks to set up an appointment to see a diabetes
+specialist.
+
+Please continue to check your blood sugar 4 times a day and take
+your insulin as prescribed to you.
 
 Followup Instructions:
-pt expired
+Please call Miller Diabetes Centre at 546-756-3070 for an
+appointment to see a diabetes specialist within the next two
+weeks.
+
+Provider: Sarah Phone:128-516-1705 Date/Time:2115-4-13 10:00
+
 
 
+"
+"Admission Date:  2183-4-21     Discharge Date:  2183-4-30
+
+Date of Birth:   2122-4-9     Sex:  M
+
+Service:  UROLOGY Dr. Mccormick
+
+HISTORY OF PRESENT ILLNESS:  This is a 61 year old male with
+left renal cell carcinoma admitted status post renal
+embolization by Interventional Radiology, in anticipation for
+a debulking left radical nephrectomy.  Approximately two
+months prior to his presentation, the patient had a chest
+x-ray obtained by primary care physician secondary to Jacqueline
+progressive cough.  The chest x-ray revealed a pulmonary
+nodule.  A chest CT scan was then obtained which revealed
+multiple bilateral pulmonary nodules.  The needle-biopsy was
+consistent with metastatic disease from renal cell carcinoma.
+An abdominal CT scan revealed a 6 cm necrotic left renal
+mass.
+
+The patient denied hematuria or bony pain, fever or chills,
+appetite changes or weight loss.  An MRI obtained on 4-10, revealed an 8.1 by 7.1 by 6 cm left renal mass.
+
+PAST MEDICAL HISTORY:
+1.  Left knee arthroscopy in 2165.
+
+MEDICATIONS:
+Ativan p.r.n.
+
+ALLERGIES:   No known drug allergies.
+
+PHYSICAL EXAMINATION:  Vital signs were temperature of 96.3
+F.; heart rate 69; blood pressure 117/64; respiratory rate
+16; O2 saturation 93% on room air.  Cor:  Regular rate and
+rhythm.  Lungs are clear to auscultation.  Abdomen soft,
+nontender, nondistended.  The patient had renal embolization
+performed on the 25th.  On 4-22, the patient was brought
+to the Operating Room where a left radical nephrectomy was
+performed.  The mass/kidney was adherent to the pancreas but
+was dissected free.  An intraoperative consultation was
+obtained with Dr. Flint.
+
+Postoperatively, the patient was on perioperative Ancef, NG
+tube, Thundera-Metropolis drain, epidural, Foley catheter, PCA,
+chest tube.  The patient was transferred to the Medical
+Intensive Care Unit postoperatively for aggressive fluid
+resuscitation.  On postoperative day one, the patient was
+transferred to the Floor.  By postoperative day two, the
+chest tube was removed.  A chest x-ray obtained after
+removing the chest tube revealed no pneumothorax.
+
+The patient continued to ambulate and await return of bowel
+function.  On postoperative day five, the patient's epidural
+and NG tube were removed.  A Physical Therapy consultation
+was obtained at that time also.  On postoperative day six,
+the patient's Foley catheter was removed.  On postoperative
+day seven, a clear liquid diet was started as the patient
+reported some flatus.  This was tolerated well with no nausea
+or vomiting and therefore the diet was advanced to regular.
+This was also tolerated well.  All of the patient's
+medications were converted to oral form including oral pain
+control.
+
+On postoperative day eight, the Initials (NamePattern4) 228 Jackson-Metropolis drain
+was noted to be minimal, approximately 20 cc per 24 hours.  Initials (NamePattern4) 
+Jackson-Metropolis amylase was sent and the value was 110.
+Therefore, the Thundera-Metropolis was removed.
+
+LABORATORY DATA:  Upon discharge, sodium 139, potassium 3.9,
+chloride 108, bicarbonate 28, BUN 7, creatinine 1.1, glucose
+102.
+
+CONDITION AT DISCHARGE:   Stable.
+
+DISCHARGE MEDICATIONS:
+1.  Percocet one to two tablets p.o. q. four to six hours
+p.r.n. pain.
+2.  Colace 100 mg p.o. twice a day.
+3.  Ativan 1 mg p.o. q. six hours p.r.n.
+
+DISCHARGE STATUS:  Home with home Physical Therapy.
+
+DISCHARGE INSTRUCTIONS:
+1.  The patient will follow-up with Dr. Hosey, in one to two
+weeks.
+
+DISCHARGE DIAGNOSES:
+1.  Status post left radical nephrectomy.
+2.  Metastatic renal cell carcinoma.
+
+
+
+                          Margaret Castro, M.D.  L47035828
+
+Dictated By:Vera
+
+MEDQUIST36
+
+D:  2183-4-30  13:35
+T:  2183-4-30  14:01
+JOB#:  Job Number 38115
 "
 "Admission Date:  2187-8-17       Discharge Date:  2187-8-23
 
@@ -895,418 +953,183 @@ D:  2187-8-22  13:26
 T:  2187-8-22  13:33
 JOB#:  Job Number 35270
 "
-"Admission Date:  2163-1-10              Discharge Date:   2163-1-19
-
-Date of Birth:  2090-4-20             Sex:   M
-
-Service: SURGERY
-
-Allergies:
-Patient recorded as having No Known Allergies to Drugs
-
-Attending:Latonya
-Chief Complaint:
-N/V
-
-Major Surgical or Invasive Procedure:
-None
-
-
-History of Present Illness:
-72 M who is 1 week s/p R. colectomy for colon cancer, presents
-with increasing nausea and emesis for the past 2 days. He was
-discharged 3 days ago, and has had increasing abdominal
-distention since. He denies any fever or chills, and reports
-continuing to pass flatus.
-
-Past Medical History:
-HTN, BPH, GERD, arthritis, monoclonal gammopathy
-
-Social History:
-Lives with wife
-
-
-Family History:
-Mother passed away from breast cancer
-
-Physical Exam:
-At time of admission:
-
-97.4   108   95/45   25   94%RA
-A&O X 3, conversant
-PERRL, EOMI, feculent breath
-Heart irregularly irregular
-Lungs CTAB
-Abd distended, hypertympanic, tender to deep palpation in
-epigastrium
-Incision C/D/I
-Rectal guiac negative
-Ext without c/c/e
+"Admission Date:  2168-10-24       Discharge Date:  2168-11-3
+
+
+Service:  CARDIOTHORACIC SURGERY
+
+HISTORY OF PRESENT ILLNESS:  This is an 80-year-old physician
+with three vessel disease, left ventricular dysfunction,
+mitral regurgitation, admitted for unstable angina.  Similar
+episode several months ago.  Thrombus in left anterior
+descending, without evidence of plaque rupture.  Exercising
+regularly without angina.  Last night, walked in cold wind,
+gave the patient angina.  During the night, recurrent
+episodes at rest, relieved by nitroglycerin.
+
+PHYSICAL EXAMINATION:  Heart rate 60, blood pressure 140/80.
+Neck:  Jugular venous pressure normal.  Lungs:  Clear to
+auscultation.  Cardiovascular:  II/VI systolic murmur.
+Extremities:  No edema.
+
+LABORATORY DATA:  Troponin less than 0.3, CK 180, MB
+negative.  Electrocardiogram showed stable, no acute changes.
+
+HOSPITAL COURSE:  The patient was admitted on 2168-10-24 to the
+Medrano Medical Center service, where the patient was continued on his aspirin,
+beta blocker, ACE inhibitor, Lipitor and Plavix.  He was
+brought to the cardiac catheterization laboratory on 2168-10-25,
+where they found the LMCA with moderate calcification and
+distal taper to the left anterior descending/RI/LCX of 70%,
+the left anterior descending with an ostial 60% calcified
+lesion, the origin of the D1 with a 50% lesion, left
+circumflex with a non-dominant vessel ostial 80% with
+mid-segment tubular 70% stenosis, and right coronary artery
+with dominant vessel proximally.
+
+Due to the extent of the patient's disease, it was decided
+that he should proceed with coronary artery bypass graft.  On
+2168-10-28, the patient was brought to the operating room, at
+which time a four vessel coronary artery bypass graft was
+performed.  The left internal mammary artery was brought to
+the left anterior descending, saphenous vein graft to the
+diagonal, saphenous vein graft to the obtuse marginal,
+saphenous vein graft to the posterior descending artery.  The
+patient tolerated the procedure well, and was brought to the
+Cardiothoracic Intensive Care Unit.
+
+Postoperatively, the patient continued to do well, and was
+extubated without incident.  The patient maintained his
+pulmonary artery pressure at 31/12, CVP of 9, coronary index
+was maintained at 2.8, and on a milrinone drip at 0.2.
+
+On postoperative day three, the patient was found to be
+maintaining his blood pressure and heart rate without the use
+of drips, and he was subsequently transferred to the Surgical
+floor.  On postoperative day three in the late afternoon, the
+patient converted to atrial fibrillation, at which time he
+was started on amiodarone of 400 three times a day as well as
+given 15 mg of intravenous Lopressor and 2 grams of
+magnesium.  The patient remained in atrial fibrillation for
+the next 48 hours, at which time it was decided to DC
+cardiovert the patient.
+
+On postoperative day six, the patient was brought to the EP
+unit and was cardioverted using 200 joules.  The patient
+converted to normal sinus rhythm and tolerated the procedure
+well.  Amiodarone was subsequently continued.
+
+On postoperative day seven, the patient converted back to
+atrial fibrillation and it was believed at that time that the
+patient should remain rate controlled, so the amiodarone was
+decreased to 200 mg once daily and the patient was started on
+his previous dose of atenolol 25 mg once daily.  The patient
+was heparinized throughout his entire course of atrial
+fibrillation and remained heparinized until his INR reached
+greater than 2.0.
+
+DISCHARGE STATUS:  Good
+
+DISCHARGE DIAGNOSIS:  Status post coronary artery bypass
+graft x 4 complicated by atrial fibrillation
 
-NGT with 2L feculent output
-
-Pertinent Results:
-2163-1-10: PT-12.4 PTT-20.4* INR(PT)-1.0
-PLT COUNT-416# WBC-8.1 RBC-3.94* HGB-11.4* HCT-32.7* MCV-83
-MCH-28.8 MCHC-34.8 RDW-13.3
-ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-6.1*# MAGNESIUM-4.2*
-CK-MB-7 cTropnT-<0.01
-ALT(SGPT)-53* AST(SGOT)-80* CK(CPK)-377* ALK PHOS-203*
-AMYLASE-108* TOT BILI-0.6
-LIPASE-148*
-
-Brief Hospital Course:
-On 2163-1-10 Mr. Michael was admitted to the surgery service under
-the care of Dr. Melancon. He had been discharged 3 days prior
-after having a right colectomy for colon cancer. He was
-readmitted with a partial SBO, ARF, and new onset of a. fib. He
-was initially admitted to the ICU for volume resuscitation and
-heart rate control. An NG tube was place and initally put out
-over 2 liters of feculent material. After converting in and out
-of atrial fibrillation, Mr. Michael was started on amiodarone
-and heparin. By HD 3 he remained in sinus rhythm. He was
-transferred out of the ICU on HD 6 when is renal status had
-improved and his HR and BP were stable. His diet was slowly
-advanced after his NGT was removed. During this time he was
-treated for a UTI with cipro. He was also started on Zosyn when
-an abdominal CT revealed a small fluid collection in the RUQ. He
-was transitioned to po Levo and Flagyl. By HD 10, Mr. Michael
-was tolerating a regular diet, ambulating with minimal
-assistance, and therapeutic on his coumadin. He was discharged
-home with instructions to follow-up with his PCP for INR checks,
-cardiology, and Dr. Melancon.
-
-Medications on Admission:
-atenolol 50', doxazosin 4', amlodipine 5', lisinopril 10',
-nexium 40, colace, percocet, klonapin
-
-Discharge Medications:
-1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
-times a day).
-Disp:*135 Tablet(s)* Refills:*2*
-2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
-(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
-Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
-3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
-a day): Please take 2 pills twice a day for 3 days, then 2 pills
-once a day for 7 days, and then 1 pill once a day from then on.
-Disp:*120 Tablet(s)* Refills:*2*
-4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
-
-5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
-6. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
-Q6H (every 6 hours) as needed.
-Disp:*qs 1* Refills:*2*
-7. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime:
-Adjust dose based on INR.
-Disp:*90 Tablet(s)* Refills:*2*
-8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
-24 hours) for 4 days.
-Disp:*4 Tablet(s)* Refills:*0*
-9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
-times a day) for 4 days.
-Disp:*12 Tablet(s)* Refills:*0*
-10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 5-12
-hours.
-Disp:*50 Tablet(s)* Refills:*0*
-11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
-Disp:*60 Capsule(s)* Refills:*2*
-
-
-Discharge Disposition:
-Home
-
-Discharge Diagnosis:
-Partial small bowel obstruction s/p R. colectomy
-New onset A. fib.
-Acute renal failure
-
-
-Discharge Condition:
-Good
+DISCHARGE MEDICATIONS:
+1.  Atenolol 25 mg by mouth once daily
+2.  Amiodarone 200 mg by mouth once daily
+3.  Warfarin 5 mg by mouth once daily
+4.  Calcium carbonate 500 mg by mouth twice a day
+5.  Aspirin 325 mg by mouth once daily
+6.  Colace 100 mg by mouth twice a day
+7.  Lasix 20 mg by mouth every 12 hours for one week
+8.  K-Dur 20 mg by mouth every 12 hours for one week
 
 
-Discharge Instructions:
-Please call your doctor or go to the ER if you experience any of
-the following: high fevers >101.5, severe pain, increasing
-shortness of breath, chest pain, palpitations, or worsening
-nausea/emesis. Please follow-up with your primary care doctor
-regarding your coumadin dose. Also please follow-up with
-cardiology.
 
-Followup Instructions:
-Provider: Geraldine,Crystal Henrietta.  688-710-1461  Follow-up
-appointment should be in 2 weeks
-Provider: Geraldine,Olga Henrietta. (CARDIOLOGY)  504-466-7865  Call to
-schedule appointment
-Provider: Geraldine,Crystal Henrietta. (PCP)  870-348-1117  Call to schedule
-appointment
 
+                            Vanessa Schill, M.D.  I60652135
 
+Dictated By:Nguyen
+MEDQUIST36
 
+D:  2168-11-2  21:06
+T:  2168-11-3  00:00
+JOB#:  Job Number 95629
 "
-"Admission Date:  2159-10-9       Discharge Date:  2159-10-16
-
-Date of Birth:   2091-9-13       Sex:  M
-
-Service:
-HISTORY OF PRESENT ILLNESS:  The patient is a 68-year-old
-gentleman with a left meningioma diagnosed two weeks prior to
-admission.  The patient had left head pain with expressive
-aphasia and then seizure.  He was taken to
-Davis Memorial Hospital Hospital where CT of the brain showed this
-
-PAST MEDICAL HISTORY:  Diabetes.
-
-PAST SURGICAL HISTORY:  Bilateral hip replacement, the left
-in 2151, the right 2152.  Cataract surgery in 2156.
-
-ALLERGIES:  NO KNOWN DRUG ALLERGIES.
-PHYSICAL EXAMINATION:  General:  He was an overweight
-gentleman.  He was cooperative but a poor historian.  HEENT:
-Pupils equal, round and reactive to light.  Extraocular
-movements full.  Right palate was soft but did not fully rise
-with phonation.  His uvula was deviated to the left.  Tongue
-midline.  Smile symmetric.  Shoulder shrug intact.  Chest:
-Rhonchi in the posterior breath sounds and expiratory
-wheezes, otherwise clear anteriorly.  Cardiovascular:  S1 and
-S2.  Distant heart sounds.  Abdomen:  Soft, nontender,
-nondistended.  Negative bruits.  Extremities:  No edema.  He
-had 2+ pulses.  Gait was unsteady secondary to his hip
-replacements.  Neurological:  Intact.
-
-LABORATORY DATA:  Head CT showed a left frontotemporal dural
-based lesion consistent with meningioma.
-
-HOSPITAL COURSE:  The patient underwent a left frontotemporal
-craniotomy for excision of meningioma without intraoperative
-complications.  Postoperatively the patient was agitated and
-confused.  It was discovered that the patient has a
-significant alcohol history.  The patient was then
-transferred to the Intensive Care Unit for close monitoring
-on postoperative day #1 and was given Ativan for DTs.
-
-He remained in the Intensive Care Unit until 2159-10-13, and was then transferred to the regular floor where he
-was seen by Physical Therapy and Occupational Therapy.  On
-10-16, the patient was found to be safe for discharge
-to home with follow-up home physical therapy and occupational
-therapy.  His mental status cleared. His sitter was
-discontinued.  He was discharged to home in stable condition.
-His staples were removed prior to discharge.  His incision
-was clean, dry, and intact.
-
-DISCHARGE MEDICATIONS:  He will be weaned from Decadron
-starting at 4 mg p.o. q.12 hours and weaned off over 6-7
-days.  He is also to remain on Dilantin 200 mg p.o. b.i.d.,
-Zantac 150 mg p.o. b.i.d.
-
-FOLLOW-UP:  He will follow-up with Dr. Paul in one month.
-
-CONDITION ON DISCHARGE:  He was stable at the time of
-discharge.
-
-
+"Name:  Julia, Latosha                    Unit No:  22958
 
+Admission Date:  2106-2-15     Discharge Date: 2106-3-23
 
+Date of Birth:   2024-2-4     Sex:  M
 
+Service:
 
-                            Stacey Helwig, M.D.  P86678299
+ADDENDUM:  This is an addendum starting 2106-2-15.
+
+1.  CARDIOVASCULAR:  The patient admitted initially for
+worsening congestive heart failure and was sent to the
+Coronary Care Unit for diuresis with a Swan-Ganz catheter for
+Thundera therapy.  The patient was aggressively diuresed to the
+point of developing hypernatremia and dehydration with
+worsening renal function.  Eventually, the patient was
+discharged to the floor.
+
+From a cardiovascular standpoint, the patient remained stable
+for the rest of his stay; however, when the patient developed
+a respiratory arrest in the hospital on 2106-2-23 the
+patient subsequently became hypotensive requiring multiple
+pressors.  Likely the patient had sepsis physiology.  A
+Swan-Ganz catheter was reintroduced in the Coronary Care Unit
+which showed the patient having elevated cardiac output and
+decreased systemic vascular resistance consistent with septic
+physiology.
+
+The patient was started on broad spectrum antibiotics and was
+put on multiple pressors including Levophed and pitressin.
+However, after further discussion with the patient's
+daughters, the patient was able to be made comfort measures
+only and pressors were discontinued, and the patient remained
+off pressors until expiration.
+
+2.  PULMONARY:  Again, the patient was doing well until
+hypoxic respiratory arrest on 2106-2-23 thought secondary
+to an aspiration episode.  The patient also with large
+bilateral pleural effusions.  The patient underwent bilateral
+thoracentesis which revealed a transudative fluid secondary
+to congestive heart failure or malnutrition with low oncotic
+pressure.  The patient was initially intubated after his
+respiratory arrest; however, again, after discussion with the
+family, the patient had a terminal extubation and was then
+able to maintain decent saturations with a nonrebreather and
+finally face mask.  The patient was started on a morphine
+drip for comfort.  Unfortunately, the patient eventually
+developed a respiratory arrest and expired.
+
+3.  INFECTIOUS DISEASE:  The patient initially treated for a
+line sepsis with vancomycin.  However, again, after the
+patient's hypoxic arrest on 2-23, the patient became
+hypotensive; likely secondary to aspiration and multiorgan
+system failure.  The patient was covered with broad spectrum
+antibiotics.  No organisms were cultured.  Again, after
+discussion with the patient's daughters, antibiotics were
+withdrawn and the patient was made comfortable.
+
+The patient expired on 2106-3-4.  Time of death at
+7:07 p.m.  The patient had been on a morphine drip titrated
+to comfort prior to expiration.  A family meeting was held
+with both daughters who agreed to this treatment course.  One
+daughter was present at the bedside at the time of
+expiration.  Autopsy was offered but refused.
+
+
+
+
+                          Sandy Joe, M.D.  U54613350
+
+Dictated By:Jammie
 
-Dictated By:Banks
 MEDQUIST36
 
-D:  2159-10-16  13:06
-T:  2159-10-16  13:08
-JOB#:  Job Number 45663
+D:  2106-3-23  17:37
+T:  2106-3-23  18:55
+JOB#:  Job Number 17745
 "
-"Admission Date:  2177-5-14              Discharge Date:   2177-5-17
-
-Date of Birth:  2146-7-21             Sex:   F
-
-Service: SURGERY
-
-Allergies:
-Dilaudid
-
-Attending:Bruce
-Chief Complaint:
-ventral hernia
-
-Major Surgical or Invasive Procedure:
-umbilical and ventral hernia repair
-
-History of Present Illness:
-30yo female currently on HD, had PD catheter removed in September
-2176, with ongoing complaint of pain from an umbilical hernia.
-
-Past Medical History:
-- ESRD since 2174-8-29, currently on HD via tunneled line
-- Peritonitis 8-7
-- Type I DM complicated by neuropathy and nephropathy
-- Bilateral cataract surgeries
-- Ventral Hernia
-
-
-Social History:
-- Lives with her mother, + tobacco history, social ETOH,
-marijuana use noted in history
-
-
-
-Family History:
-DM type II, otherwise NC
-
-
-Physical Exam:
-upon admission:
-Gen - NAD, AOx3
-CV - RRR, S1/S2 appreciated
-Chest - CTAB
-Abdomen - soft, nontender, nondistended, well healed PD cath
-removal site left abdomen, normal bowel sounds
-Ext - no C/C/E
-
-Pertinent Results:
-upon admission:
-WBC-7.9 RBC-3.72* Hgb-10.9* Hct-34.8* MCV-94 MCH-29.2 MCHC-31.2
-RDW-18.1* Plt Ct-239
-Glucose-78 UreaN-21* Creat-6.4*# Na-144 K-3.6 Cl-104 HCO3-30
-AnGap-14
-Calcium-8.4 Phos-3.3 Mg-2.1
-
-2177-5-17 07:30AM BLOOD WBC-7.1 RBC-3.83* Hgb-11.4* Hct-36.3
-MCV-95 MCH-29.9 MCHC-31.5 RDW-17.8* Plt Ct-253
-2177-5-17 04:40AM BLOOD Glucose-122* UreaN-20 Creat-8.5*# Na-140
-K-3.9 Cl-100 HCO3-24 AnGap-20
-
-Brief Hospital Course:
-The patient was admitted to the West-1 surgery for scheduled
-ventral/umbilical herniorrhaphy on 2177-5-14, which went well
-without complication (please refer to Operative Note for
-details). In the PACU, the patient experienced significant pain
-control issues as well as nausea and emesis.  After
-stabilization and improvement in symptoms, the patient was
-transferred to the inpatient floor in stable condition.
-
-Neuro: The patient received dilaudid with adequate pain control,
-however patient experienced nausea likely related to narcotic
-analgesia.  She was transitioned to oxycodone during her
-admission after improvement in surgical site pain.
-
-CV: The patient remained stable from a cardiovascular
-standpoint; vital signs were routinely monitored.
-
-Pulmonary: The patient remained stable from a pulmonary
-standpoint; vital signs were routinely monitored. Good pulmonary
-toilet, early ambulation and incentive spirrometry were
-encouraged throughout hospitalization.
-
-GI/GU/FEN: Post-operatively, diet was advanced when appropriate
-and tolerated. Patient's intake and output were closely
-monitored, and IV fluid was adjusted when necessary.
-Electrolytes were routinely followed, and repleted when
-necessary. Patient underwent scheduled hemodialysis while an
-inpatient.
-
-ID: The patient's white blood count and fever curves were
-closely watched for signs of infection.
-
-Endocrine: Post-operatively, the patient's blood sugar levels
-were monitored and a sliding scale implemented.
-
-Hematology: The patient's complete blood count was examined
-routinely; no transfusions were required.
-
-Prophylaxis: The patient received subcutaneous heparin and
-venodyne boots were used during this stay; was encouraged to get
-up and ambulate as early as possible.
-
-At the time of discharge, the patient was doing well, afebrile
-with stable vital signs. The patient was tolerating a regular
-diet, ambulating, voiding without assistance, and pain was well
-controlled. The patient received discharge teaching and
-follow-up instructions with understanding verbalized and
-agreement with the discharge plan.
-
-Medications on Admission:
-Carvedilol 12.5 mg Gaudio Medical Center, Sensipar 30 mg Tdaily, Furosemide 60 mg
-daily, Novolog
-100 unit/mL Solution per sliding scale QID, Glargine 100 unit/mL
-Solution
-15 units qhs- fluctuates with appetite and blood sugars,
-Lisinopril 20 mg daily, Oxycodone 5 mg Tablet 11-30 every four (4)
-hours as needed for pain   Sevelamer HCl 800 mg TID with meals,
-Travoprost (Benzalkonium) [Travatan]
-0.004 % Drops 1 gtt ou hs, Aspirin 81 mg daily, B complex
-Vitamins daily,  Folic Acid 1 mg daily,
-
-
-Discharge Medications:
-1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
-a day).
-2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-
-3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
-(Daily).
-4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-
-5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
-PO DAILY (Daily).
-6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-
-7. B Complex Vitamins     Capsule Sig: One (1) Cap PO DAILY
-(Daily).
-8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
-times a day).
-9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
-day) as needed for constipation.
-10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
-(at bedtime).
-11. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
-W/MEALS (3 TIMES A DAY WITH MEALS).
-12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
-hours) as needed for pain.
-Disp:*30 Tablet(s)* Refills:*0*
-13. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
-Subcutaneous once a day.
-14. Novolog 100 unit/mL Solution Sig: follow sliding scale
-Subcutaneous four times a day.
-15. Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection
-once a week.
-
-
-Discharge Disposition:
-Home With Service
-
-Facility:
-South Park Dialysis South Park
-
-Discharge Diagnosis:
-ESRD
-Ventral hernia repair
-
-
-Discharge Condition:
-Mental Status: Clear and coherent.
-Level of Consciousness: Alert and interactive.
-Activity Status: Ambulatory - Independent.
-
-
-Discharge Instructions:
-Please call Dr.Doris office 903-535-3620 if you have any of
-the warning signs listed below.
-Continue with your usual dialysis schedule
-No heavy lifting/straining
-No driving while you are taking pain medication
-
-Followup Instructions:
-Provider: James Myers, MD Phone:903-535-3620
-Date/Time:2177-5-30 3:40
-Provider: Ray Alysia, MD Phone:903-535-3620
-Date/Time:2177-6-13 10:40
-Provider: Vickie Michaud, MD Phone:512-597-7329 Date/Time:2177-7-4
-10:40
-
-
-
-Completed by:2177-5-21"