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: 2188-1-12 Discharge Date: 2188-1-25 Date of Birth: 2148-1-24 Sex: M Service: 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 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 Date of Birth: 2074-3-9 Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:Jaime Chief Complaint: struck on head by large beam Major Surgical or Invasive Procedure: anterior cervical fusion 3-21 posterior cervical fusion 3-24 Open trach, PEG 3-29 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. Past Medical History: healthy Social History: married Family History: non-contributory 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. 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 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). Medications on Admission: none 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). Discharge Disposition: Extended Care Facility: True Corporation Discharge Diagnosis: C4-6, T2-3 fractures with quadraplegia Discharge Condition: stable Discharge Instructions: tracheostomy care gastrostomy care " "Admission Date: 2126-10-24 Discharge Date: 2126-10-30 Date of Birth: 2063-1-14 Sex: M Service: CSU 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. 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. ALLERGIES: No known drug allergies. 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. 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. 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. 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. 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 " "Admission Date: 2195-10-19 Discharge Date: 2195-10-19 Date of Birth: 2156-3-29 Sex: M Service: MEDICINE Allergies: Fish Protein / Shellfish Derived Attending:Alexis Chief Complaint: multi-organ failure Major Surgical or Invasive Procedure: 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. Past Medical History: Hypertension Sleep apnea Social History: drinks one pint of rum or vodka daily, last drink was 4 days ago. No cigarettes or tobacco. No illicit drug use. Family History: Mother and father with Diabetes. 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. 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 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. . # 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. . # 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. # Myocardial infarction: Patient had ST elevations in V1 through V4, likely secondary to demand ischemia in light of severe hypotension. Patient expired at 20:35 on 2195-10-19. His wife requested autopsy to determine cause of death. Medications on Admission: amlodipine celexa lisinopril Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired " "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: 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 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 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 " "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. Stacey Helwig, M.D. P86678299 Dictated By:Banks MEDQUIST36 D: 2159-10-16 13:06 T: 2159-10-16 13:08 JOB#: Job Number 45663 " "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"