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: 2143-11-10 Discharge Date: 2143-12-11 Date of Birth: 2089-2-6 Sex: M Service: MEDICINE 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 " "Admission Date: 2149-11-26 Discharge Date: 2149-11-27 Service: MEDICINE Allergies: Penicillins Attending:Rita Chief Complaint: Sepsis Major Surgical or Invasive Procedure: ERCP/stent placement History of Present Illness: 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: Recent PE/DVT Afib HTn Hypotension Hypothyroidism CAD ? mild CHF Social History: lives with daughter and granddaughter, functional at home , non-smoker, no alcohol use Family History: NC Physical Exam: 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: 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: 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: ASA 325mg Lopressor 25mg Patrick Clinic Amiodarone 200mg Patrick Clinic Coumadin 2.5mg daily Isosorbide 60mg daily Levothyroixine 50mcg daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: 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: expired Discharge Instructions: expired Followup Instructions: expired " "Admission Date: 2182-2-23 Discharge Date: 2182-2-28 Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Drew Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ERCP 2182-2-24 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 Social History: Quit tobacco 30 years ago Rarely drinks EtOH 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) 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. " "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. 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: 2115-2-9 Discharge Date: 2115-2-10 Date of Birth: 2075-6-15 Sex: F Service: MEDICINE Allergies: Shellfish Attending:Wendy Chief Complaint: DKA Major Surgical or Invasive Procedure: None History of Present Illness: 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: Type I Diabetes Mellitus with mild retinopathy, las A1C 10% Social History: 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: Grandmother had diabetes and leukemia. Mother has benign breast disease. Son recently diagnosed with DM type I. Physical Exam: 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: CXR: No acute process Brief Hospital Course: 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. # 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 # Ppx: Received heparin products. # Code: full code Medications on Admission: 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: 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: Home Discharge Diagnosis: Diabetic Ketoacidosis Discharge Condition: Stable, Afebrile Discharge Instructions: 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: 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 Service: Orthopedic Surgery HISTORY OF PRESENT ILLNESS: Mrs. Grant is a 87-year-old woman who was transferred to Blair Clinic from Morris Clinic with a diagnosis of left intertrochanteric hip fracture. The patient fell earlier on the day of admission and subsequent to this was unable to walk secondary to pain. The patient denied weakness, numbness or paresthesias in left lower extremity. PAST MEDICAL HISTORY: 1. Hypertension 2. Cataract ADMISSION MEDICATIONS: 1. Toprol 2. Calcium 3. Aspirin 81 mg po q day ALLERGIES: No known drug allergies. PHYSICAL EXAM: GENERAL: Pleasant 87-year-old woman in no acute distress. VITAL SIGNS: Temperature 98??????, blood pressure 135/80, heart rate 80, respiratory 18, O2 saturation 98% on room air. HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and reactive to light. Oropharynx clear. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm, no murmurs, rubs or gallops. ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. EXTREMITIES: Left lower extremity was shortened and externally rotated. There was focal tenderness in the great trochanter area of the left hip. Strength was 5-13 in left toes, ankle and knee. Sensation was intact. Pulses were normal, including popliteal, DP and PT pulses. The rest of the physical exam was unremarkable. X-RAYS revealed a left intertrochanteric fracture. Chest x-ray was normal. Electrocardiogram was within normal limits. LABS: White blood cell count was 6.7, hematocrit was 34, platelets 187. Sodium, potassium chloride, bicarbonate, BUN, creatinine and glucose were all within normal limits. HOSPITAL COURSE: The patient was taken to the Operating Room on 2187-8-19 and underwent open reduction and internal fixation of left intertrochanteric fracture. For more details about the operation, please refer to the operative note from that date. The patient did not have any postoperative complications. The operation was under general anesthesia. Preoperatively, the patient was started on Coumadin for deep venous thrombosis prophylaxis. The patient also received 48 hours of Kefzol perioperatively. The patient's diet was advanced as tolerated. The patient was noted to have some mild difficulty with swallowing and a swallow study consult was obtained. It was determined the patient did not have any significant physiological or mechanical problems and those difficulties were likely due to anxiety the patient was experiencing postoperatively. The patient eventually successfully tolerated a regular diet. The patient was switched to oral pain medications successfully. The patient made good progress with physical therapy and was able to bear weight and walk successfully. The patient will be discharged to the rehabilitation center. During the hospital stay, the patient's hematocrit has remained stable. DISCHARGE MEDICATIONS are identical to the medications on admission, plus Coumadin 2.5 mg po q day for target INR of 1.5. David Farber, M.D. R43148808 Dictated By:Dylan MEDQUIST36 D: 2187-8-22 13:26 T: 2187-8-22 13:33 JOB#: Job Number 35270 " "Admission Date: 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 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 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 " "Name: Julia, Latosha Unit No: 22958 Admission Date: 2106-2-15 Discharge Date: 2106-3-23 Date of Birth: 2024-2-4 Sex: M Service: ADDENDUM: This is an addendum starting 2106-2-15. 1. CARDIOVASCULAR: The patient admitted initially for worsening congestive heart failure and was sent to the Coronary Care Unit for diuresis with a Swan-Ganz catheter for Thundera therapy. The patient was aggressively diuresed to the point of developing hypernatremia and dehydration with worsening renal function. Eventually, the patient was discharged to the floor. From a cardiovascular standpoint, the patient remained stable for the rest of his stay; however, when the patient developed a respiratory arrest in the hospital on 2106-2-23 the patient subsequently became hypotensive requiring multiple pressors. Likely the patient had sepsis physiology. A Swan-Ganz catheter was reintroduced in the Coronary Care Unit which showed the patient having elevated cardiac output and decreased systemic vascular resistance consistent with septic physiology. The patient was started on broad spectrum antibiotics and was put on multiple pressors including Levophed and pitressin. However, after further discussion with the patient's daughters, the patient was able to be made comfort measures only and pressors were discontinued, and the patient remained off pressors until expiration. 2. PULMONARY: Again, the patient was doing well until hypoxic respiratory arrest on 2106-2-23 thought secondary to an aspiration episode. The patient also with large bilateral pleural effusions. The patient underwent bilateral thoracentesis which revealed a transudative fluid secondary to congestive heart failure or malnutrition with low oncotic pressure. The patient was initially intubated after his respiratory arrest; however, again, after discussion with the family, the patient had a terminal extubation and was then able to maintain decent saturations with a nonrebreather and finally face mask. The patient was started on a morphine drip for comfort. Unfortunately, the patient eventually developed a respiratory arrest and expired. 3. INFECTIOUS DISEASE: The patient initially treated for a line sepsis with vancomycin. However, again, after the patient's hypoxic arrest on 2-23, the patient became hypotensive; likely secondary to aspiration and multiorgan system failure. The patient was covered with broad spectrum antibiotics. No organisms were cultured. Again, after discussion with the patient's daughters, antibiotics were withdrawn and the patient was made comfortable. The patient expired on 2106-3-4. Time of death at 7:07 p.m. The patient had been on a morphine drip titrated to comfort prior to expiration. A family meeting was held with both daughters who agreed to this treatment course. One daughter was present at the bedside at the time of expiration. Autopsy was offered but refused. Sandy Joe, M.D. U54613350 Dictated By:Jammie MEDQUIST36 D: 2106-3-23 17:37 T: 2106-3-23 18:55 JOB#: Job Number 17745 "