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train_43041 | completed | 5df87a85-7c40-4695-93bb-338f1ae68b49 | Medical Text: Admission Date: [**2130-11-13**] Discharge Date: [**2130-12-6**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman with a history of congestive heart failure, peripheral
vascular disease, Type 2 diabetes mellitus, and Parkinson's
disease, who was admitted after being found unresponsive at
home. The patient was in her usual state of health until 1
P.M. on the day of admission, when she was found by her
cousin, who lives with her. The patient was unresponsive,
apparently no longer than 30 seconds. She slumped forward,
and EMS was called. There were no preceding palpitations,
shortness of breath, chest pain, focal weakness, dysarthria,
bowel or bladder incontinence, or seizure activity noted.
EMS noted the patient to have a finger stick blood glucose of
240, atrial fibrillation on the monitor, with a rate of 100,
blood pressure of 136/palp, respiration rate of 4, and
initially unresponsive. Her pupils were equal, round and
reactive to light.
The patient was intubated and, during intubation, she was
noted to have increased agitation. She was given 2 mg of
Versed, successfully intubated, and sent to [**Hospital1 346**], where she was immediately brought
to the Medical Intensive Care Unit. Upon arrival, she was
hemodynamically stable.
PAST MEDICAL HISTORY:
1. Congestive heart failure, last echocardiogram in [**2130-8-14**] showed mild symmetric left ventricular hypertrophy,
an ejection fraction of greater than 55%, and 1+ aortic
insufficiency and mitral regurgitation. There was normal
right ventricular function. She was admitted in [**2130-8-14**] with increasing peripheral edema and orthopnea. She was
diuresed 3 liters, ruled out by enzymes, and had a negative
ETT MIBI.
2. Hypercholesterolemia
3. Hypertension
4. Peripheral vascular disease status post bilateral carotid
endarterectomy in [**2121**]
5. Type 2 diabetes mellitus with peripheral neuropathy and
glaucoma
6. Parkinson's disease, followed by neurologist Dr. [**Last Name (STitle) **]
7. Osteoarthritis
ALLERGIES: There are no known drug allergies.
MEDICATIONS: Sinemet 25/100 one-half tablet by mouth three
times a day, Lidoderm patch, Timoptic and Xalatan eyedrops
one drop per eye every day, Miacalcin spray one spray
alternating nostrils once daily, NPH insulin 5 units
subcutaneously every morning, Neurontin 600 mg by mouth three
times a day, atenolol 75 mg by mouth once daily, lasix 40 mg
by mouth every Monday, Wednesday and Friday, Protonix 40 mg
by mouth once daily, Zestril 5 mg by mouth once daily.
SOCIAL HISTORY: She lives with her cousin. She is
minimally ambulatory at baseline. She uses a wheelchair and
a walker, needs help with her activities of daily living.
She quit tobacco 15 years ago. The patient had been at
[**Hospital3 2732**] Home for approximately one and a half
months following her [**Month (only) 359**] admission for congestive heart
failure. While there, she had been placed on supplemental
oxygen by nasal cannula. She was discharged home on oxygen
one and a half weeks prior to her readmission.
FAMILY HISTORY: Father died of a myocardial infarction at
age 39.
REVIEW OF SYSTEMS: Stable four-pillow orthopnea, decreasing
peripheral edema over baseline, stable dyspnea on exertion,
no chest pain, oxygen 2 liters nasal cannula at home, no
fevers or chills, no abdominal pain, no change in urinary
symptoms, no cough.
PHYSICAL EXAMINATION: Temperature 98.4, heart rate 82 and
regular, blood pressure 154/57, respirations 15, oxygen
saturation 96%, weight 90.9 kg. Ventilated on IMV mode with
tidal volumes of 700, rate of 10, pressure support of 5, and
PEEP of 5, with FIO2 of 100%. In general, intubated,
responding to questions, appears comfortable. Head, eyes,
ears, nose and throat: Normocephalic, atraumatic,
extraocular movements intact, pupils equal, round and
reactive to light, mucous membranes moist, no lesions. Neck:
Jugular venous pressure difficult to determine. There is a
left carotid bruit. Cardiovascular: Regular rate and
rhythm, normal S1 and S2, I/VI systolic murmur at the upper
sternal border. Lungs: Decreased breath sounds at the right
base, otherwise clear to auscultation bilaterally, without
rales, rhonchi or wheezes. Abdomen: Soft, obese,
nondistended, right lower quadrant and left lower quadrant
mildly tender, no rebound, no guarding, positive bowel
sounds. Extremities: Trace pretibial edema bilaterally, no
cords. Rectal: Guaiac negative, normal tone. Neurological:
Cranial nerves II through XII intact, moving all extremities,
equal strength, [**3-18**] throughout upper and lower. Sensation
normal throughout. Patellar reflexes 2+ bilaterally, absent
ankle jerks. Left upper extremity with resting tremor.
LABORATORY DATA: On admission, white blood cells 4.1,
hematocrit 29.2, platelets 227. PT 13.3, PTT 29.9, and INR
1.2. Sodium 138, potassium 4.8, chloride 94, bicarbonate 33,
BUN 30, creatinine 1.2, glucose 121. Magnesium 2.1,
phosphate 3.7, calcium not measured. ALT 9, AST 71, alkaline
phosphatase 80, total bilirubin 0.5, albumin 3.2, serum
osmolality 298. CPK and troponin were negative. Urinalysis
was negative for urinary tract infection. Serum toxicology
screen was negative. Urine toxicology screen was positive
for benzodiazepines. Arterial blood gas was 7.55/36/220 on
100% FIO2 with the ventilator settings as listed above. CT
scan of the head showed no intracerebral bleed. Chest x-ray
showed bilateral hilar fullness and upper zone
redistribution. Electrocardiogram was normal sinus rhythm at
78, with normal axis. There were peaked T waves in Leads V2
through V6. There were no ST or T changes suggestive of
ischemia, no Q waves consistent with electrocardiogram
performed in [**2130-8-14**].
IMPRESSION: This was an 85-year-old woman with a history of
diastolic dysfunction, Type 2 diabetes mellitus, Parkinson's
disease, who was found unresponsive and intubated in the
field, but whose neurologic function upon admission appeared
to be at baseline.
HOSPITAL COURSE: Initially the patient's primary disorder
was thought to be neurologic in origin. Therefore, the
Neurology service was consulted. It was thought that perhaps
the patient had a basilar artery transient ischemic attack.
A head CT was performed, and this was negative. Therefore,
it was thought that the patient did not have a primary
neurologic event. She ruled out for myocardial infarction.
There was no recurrence of the atrial fibrillation noted on
the monitor in the field. Her aspirin, atenolol, Zestril and
Lipitor were continued.
Two days after admission, on the [**8-15**], while the
patient's cousin was visiting, the patient was noted to slump
over and become unresponsive for a second time. Rhythm strip
showed junctional escape with a heart rate of 15. She was
assumed to be in bradycardic arrest. She was intubated for a
second time, and the electrophysiology division of the
Cardiology service was consulted. She was thought to have a
sick sinus syndrome, and a DDD pacer was placed. Lasix was
given for diuresis. She received bronchoscopy, which removed
a large dried mucous plug at the tip of the endotracheal
tube. Bronchial washings from that bronchoscopy revealed
only gram-negative rods on Gram [**Last Name (LF) 2733**], [**First Name3 (LF) **] she was started on
ceftriaxone and Flagyl.
The following day, on the [**8-17**], she was extubated.
However, she required very high levels of oxygen to maintain
her saturations above 90%. To investigate this, a chest
x-ray was performed which revealed bilateral pleural
effusions, as well as cardiomegaly. An echocardiogram was
performed that showed mild symmetric left ventricular
hypertrophy, preserved left ventricular function with an
ejection fraction greater than 55%, normal right ventricular
systolic function, trace aortic regurgitation, mild mitral
regurgitation, and no pericardial effusion. There was no
change compared to the echocardiogram performed in [**2130-8-14**].
In light of these findings, we postulated that the cause of
her poor oxygenation was multifactorial, including
restrictive lung disease from obesity and cardiomegaly, as
well as her pleural effusions. She was continued on lasix
for diuresis and, on [**11-19**], was transferred to the
general medical floor for further management.
On [**11-20**], while in the Radiology Department following an
x-ray, she was found on the stretcher with an ashen
appearance, diaphoretic, and unresponsive. A code was
called. Her portable oxygen tank was noted to be empty.
When her mask was hooked up to wall oxygen, she gradually
gained consciousness and there were no residual deficits.
On [**11-22**], she underwent thoracentesis on the right, which
was the larger of her effusions. 300 cc of serosanguinous
exudative fluid were drained. The cytology was negative.
The following day, she underwent diagnostic bronchoscopy,
which was essentially unremarkable. Later that night, she
had increasing hypoxia, a temperature of 100.8, a white count
of 14, and a chest x-ray which showed increasing bilateral
effusions. She had warm extremities. Therefore, it was felt
that she was likely in septic shock with bacterial source
being from a primary pulmonary infection. She was
transferred to the Medical Intensive Care Unit, where central
access was obtained and she was started on dopamine for
pressure support. She received noninvasive positive pressure
ventilation and nebulized treatments. A CT scan of the chest
on [**11-24**] showed moderate bilateral effusions and
multifocal opacities, consistent with pneumonia. Incidental
note was made of a left adrenal mass, most consistent with an
adenoma. Since she developed this pneumonia while she was in
the hospital, we covered her broadly with vancomycin,
ceftazidime and Flagyl. We continued with NIPPV for two more
days, but she did not significantly improve. Therefore, on
[**11-27**], she was reintubated. Fentanyl was used for
sedation, and dopamine was continued.
The following day, she received diagnostic bronchoscopy for a
specimen collection, but these grew only oropharyngeal flora.
Thus in the absence of a predominant pathogen, her antibiotic
therapy was eventually changed to levofloxacin and Flagyl on
[**11-30**]. On that same day, she was changed from assist
control mode to SIMV plus pressure support. She tolerated
this well. She had a very brief temperature spike to 101.4
on [**12-1**], but no increase in white count was noted, and
she had no subsequent temperature spikes.
In light of the patient's very slow recovery from her
pneumonia, multiple discussions were held with the patient as
well as with her family to discuss the patient's end of life
issues. The patient made it very clear that she wished to
proceed with maximal medical management providing that she
still had a chance to recover from her pneumonia. Therefore,
on [**12-5**], she received tracheotomy and percutaneous
endoscopic gastrostomy for anticipated discharge to inpatient
rehabilitation.
Additional aspects of her hospital stay were as follows:
Cardiovascular: We discontinued the patient's beta blockade
and ACE inhibitor in light of her hypotension. We continued
her Lipitor and aspirin.
Gastrointestinal: She was placed on Prevacid for
gastrointestinal prophylaxis.
Nutrition: She was fed by tube feeds via an orogastric tube,
which was later changed to a percutaneous endoscopic
gastrostomy.
Endocrine: We maintained adequate blood glucose control via
NPH insulin and a regular insulin sliding scale.
Neurology: We continued the patient on Neurontin and
Sinemet.
Hematology: The patient has a baseline anemia, which
responded well to periodic transfusion. Her baseline
hematocrit is approximately 30.0.
Prophylaxis: The patient was on heparin for deep venous
thrombosis prophylaxis, and Prevacid for gastrointestinal
prophylaxis.
Code status: With multiple discussions held with the patient
and her family, it was determined that she was Full Code.
DISPOSITION: The patient will be discharged to inpatient
rehabilitation once accepted at a rehabilitation facility.
Discharge instructions and medication list will be provided
on the discharge addendum.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2130-12-6**] 00:33
T: [**2130-12-6**] 00:56
JOB#: [**Job Number 2735**]
ICD9 Codes: 4280, 486, 0389, 4019, 2859 | [
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train_46253 | completed | 3bb1d579-dded-4d6b-97ee-2b552633a1c2 | Medical Text: Admission Date: [**2142-11-7**] Discharge Date: [**2142-11-30**]
Date of Birth: [**2071-6-4**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 yo Mandarin-speaking man who was admitted to the [**Hospital1 18**] in
[**5-25**] for evaluation of a three-week history of blurred vision
and was subsequently found to have a WBC of 300,000 and was
diagnosed with AML. He was twice leukopheresed and then was
treated with idarubicin for 3 days and a continuous infusion of
ARA-C for 7 days. A follow-up bone marrow on [**2142-7-19**] showed
remission.
Of note, the [**Hospital 228**] hospital course at that time was
complicated by the findings of interstitial pulmonary
abnormalities and pulmonary nodules on imaging studies; these
were ultimately thought to be a chronic finding, but because of
his RLL lesion, he was treated empirically for aspergillosis
with voriconazole, and he was also given a course of
levofloxacin. Further investigation following his discharge from
the hospital demonstrated that he had been treated with
gatifloxacin and azithromycin at an OSH in [**2140**] for presumed
Rhodococcus equi pneumonia (the organism was cultured from BAL
fluid at that time); the significance of this finding and the
relative adequacy of this treatment remains unclear. A sputum
culture obtained after readmission in [**7-25**] for dyspnea and
hemoptysis showed Mycobacteria gordonae (a known contaminant and
not likely to cause disease). A chest CT done [**2142-8-14**]
demonstrated a persistent spiculated nodule in his right lower
lobe, multiple opacities in the right and left upper lobes that
were more prominent than on previous examinations, unchanged
calcified mediastinal lymphadenopathy, and stable
low-attenuation liver lesions.
Since his diagnosis with AML he has been followed as an
outpatient the division of infectious diseases. In summary, his
voriconazole was discontinued [**2142-10-24**] based upon the presumption
that he appears too well to have persistant infection and the
lack of any definitive evidence (e.g. culture data) of
infection. He was scheduled to be seen in pulmonary clinic for
follow-up of the persistent collapse vs. atelectasis of his
right middle lobe out of concern for another primary malignancy.
He was seen last week in oncology clinic and was noted to have a
WBC of 19,000 without any blasts. Follow-up today in clinic
showed an asymptomatic WBC of 64,000 with 42% blasts. After
discussion the matter with his family, the patient agreed to be
admitted for treatment of relapsed AML. He was given 3 grams of
hydroxyurea orally and 300 mg of allopurinol orally in the
clinic and was then admitted to the BMT floor.
Past Medical History:
1. AML: Diagnosed in [**2142-6-21**], status-post remission induction
with 7+3 chemotherapy
2. Pulmonary disease as per HPI, s/p treatment for aspergillosis
3. Chronic micronodular pulmonary disease due to pneumoconiosis
(retired coal miner)
4. Bleeding peptic ulcer disease in [**9-/2141**]
5. Left knee surgery
6. Prolonged (two month) course of gatifloxacin and azithromycin
for possible Rhodococcus equi pneumonia [**2140**]
7. PPD negative [**8-25**]
Social History:
He worked at a coal mine for about 20 years in [**Country 651**]. Former
smoker, with a 100 pack-year smoking history; he quit smoking in
[**2139**]. No EtOH consumption. He currently lives with his wife,
daughter and son-in-law. [**Name (NI) **] has 5 children.
Family History:
His mother, who passed away 3 years ago, and his brother, whom
he has not seen for 7 years, both had tuberculosis.
Physical Exam:
Temp 97.7, BP 126/78, HR 73, RR 14, SpO2 94% RA
Gen: Mandarin-speaking only, very pleasant, comfortable, [**Location (un) 1131**]
papers in bed and ambulating around room, non-toxic
HEENT: NCAT, no sinus tenderness, pinpoint pupils bilaterally,
conjunctivae clear, OP clear, moist oral mucosa
Neck: Soft, supple, shotty submandibular adenopathy
CV: RRR, normal S1 and S2, no m/r/g
Pulm: Diminished bibasilar breath sounds but otherwise clear to
auscultation bilaterally
Abd: Soft, non-tender, mildly distended with tympany to
percussion, active bowel sounds, no organomegaly
Back: No CVA or paraspinal angle tenderness
Ext: Trace bilateral lower extremity pitting edema, 2+ DP
pulses, warm
Nodes: No palpable cervical, axillary, or inguinal adenopathy
Pertinent Results:
WBC-64.5 (N-35 Band-6 L-10 M-4 E-1 Meta-2 Blast-42) Hct-37.3
MCV-86 Plt-173
PT-12.9 PTT-32.2 INR-1.1 Fibrinogen-322
Na-142 K-4.2 Cl-109 Bicarb-27 BUN-16 Cr-1.3 Ca-9.3 Mg-2.2
Phos-3.9 Alb-4.1
ALT-14 AST-38 Alk Phos-72 TBili-0.1 LDH-817 Uric Acid-7.4
Brief Hospital Course:
71 yo man with AML, status-post idarubicin and ARA-C in [**Month (only) **]
[**2141**], initially in remission by bone marrow biopsy at that
time, now with relapsing AML/acute leukemic crisis (WBC 64,000
with 42% blasts) and mild acute renal failure.
1. Relapsing AML:
Patient presented with recurrence of his AML. He was managed
with first Hydrea,
then re-induction with MEC chemotherapy. He tolerated this
well.
He developed neutropenia and spiked temperatures. His initial
infectious work up was unrevealing, with the exception of
bilateral basilar lung disease on chest xray.
Sputum cultures only revealed sparse oropharyngeal flora. He
was managed with
empiric cefepime/vancomycin.
2. Pulmonary: Elaborate and complicated history of pulmonary
disease with possible superimposed infectious disease (recent
fungal infection? remote Rhodococcus pneumonia?) as detailed in
the HPI. Has completed course of antifungal therapy for
aspergillus, as well as antibiotic therapy for rhodococcus. He
has a history of
coal-worker's pneumoconiosis as well.
3. Acute Renal Failure: Admission creatinine elevated to 1.3
from a baseline of 0.9. Likely etiologies include an effect of
tumor lysis vs. pre-renal azotemia. This returned to baseline
with hydration.
On [**11-27**] (Hospital day 20), the pt. was transferred to the
ICU for persistent tachycardia (uncontolled atrial fibrillation)
and hypotension, presumed to be related to sepsis. Shortly
after arrival to the ICU, he was intubated and placed on a
ventilator for hypoxic respiratory failure. Over the course of
the next three hospital days, the pt's. clinical status
deteriorated despite treatment with multiple antibiotics,
pressors and mechanical ventilation. The pt. became profoundly
acidemic on the 23rd hospital day and progressively hypotensive
despite increasing doses of pressors. A family meeting was held
given his deteriorating status but it was decided to continue
all current treatment, however, it was determined that CPR was
not indicated. Shortly thereafter, the pt. went into asystole.
He was pronounced deceased at 2:02pm on [**2142-11-30**].
Medications on Admission:
None.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 5849, 5070, 4280, 4019 | [
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train_45536 | completed | 08edab0d-a822-488a-b03f-f078867c9d42 | Medical Text: Admission Date: [**2133-3-16**] Discharge Date: [**2133-4-3**]
Date of Birth: [**2084-9-18**] Sex: M
Service:
ADDENDUM:
DISCHARGE MEDICATIONS:
1. Diltiazem 60 mg p.o. q.i.d.
2. Lasix 20 mg p.o. b.i.d.
3. Nystatin swish and swallow q.i.d.
4. Captopril 25 mg p.o. t.i.d.
FOLLOW-UP: He will be followed by Dr. [**First Name4 (NamePattern1) 1704**] [**Last Name (NamePattern1) 52941**] upon
discharge from rehabilitation. He will have an appointment
with Dr. [**Last Name (STitle) **] when appropriate. He will have his sternal
staples discontinued on [**2133-4-8**].
DISCHARGE DIAGNOSIS:
1. Acute type A aortic dissection.
2. Hypertension.
3. Atrial fibrillation.
4. Cerebrovascular accident.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2133-4-3**] 01:50
T: [**2133-4-3**] 14:55
JOB#: [**Job Number 52942**]
ICD9 Codes: 4241, 4280, 4019 | [
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train_45986 | completed | 722fb8e7-251f-45d0-87b5-90f69aefb3b8 | Medical Text: Admission Date: [**2167-5-17**] Discharge Date: [**2167-5-18**]
Date of Birth: [**2087-3-31**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Levaquin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
na
History of Present Illness:
80 yo female with h/o severe COPD (on home O2), diastolic CHF
who presented to ED this AM with severe dyspnea and hypoxia.
She is currently on BiPap therefore history is somewhat limited.
She reports having cough, maybe a fever but didn't check her
temp at home. She states her breathing has gotten worse over
the last few days to about a week or so. She also reports
having some mild lower extremity edema. She has been having
some chest tightness as well. She denies any other symptoms.
She has been taking her nebs, but otherwise feels she was
getting worse.
.
In the ED, initial vs were: T 98.4 P 113 BP 138/46 R O2 sat.
Patient was given CTX and azithromycin in the ER for ? PNA on
CXR. Her initial O2 sat was unable to be read in triage, then
in the room, was in the low 80s, and improved to 92% on NRB.
Given that she had barely any air movement, she was started on
BiPAP. After about 25 mins of BiPAP, her ABG was 7.27/102/72.
Her FiO2 was decreased to 35% because she was having apneic
episodes, and with that, her repeat ABG was 7.34/79/57. She was
also given steroids and nebs in the ER, then admitted to the
MICU for further management.
.
On the floor, she reports feeling dyspneic, but slightly better.
Past Medical History:
severe COPD - on 2L home O2 FEV1: 0.56 (36%) FEV1/FVC: 48
(71%), refuses steroids
DM-no meds
Recurrent choledocholithiasis, s/p cholecystectomy, s/p ERCP X8
for stone retrieval/stent placement (Dr. [**Last Name (STitle) **]
Depression/Anxiety
Severe Right hip arthritis
Aneurysm with cranial clips x2
PVD: [**1-7**] doppler right significant superficial femoral and
tibial artery occlusive disease. On the left, there
is moderate popliteal/tibial arterial occlusive disease.
Diastolic heart failure with acute CHF during previous admission
Rhinitis
Social History:
The patient currently lives at [**Location 10138**] [**Hospital3 **]
facilily. At baseline she is able to walk with a walker, feed
her self, bath and dress herself but has meals prepared for her.
She has two sons involved in her life and care, [**Doctor First Name **] and [**Doctor Last Name **]
but is unable to recall if 1 has been designated HCP, she would
prefer both help with decisions for now.
Tobacco: 2 PPD x 40 years, quit many years ago
ETOH: None
Illicits: None
Family History:
Sons are healthy. No pulmonary disease, no h/o recurrent GB
stones per pt.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
[**2167-5-18**] 04:10AM BLOOD WBC-5.2 RBC-3.82* Hgb-9.6* Hct-32.0*
MCV-84 MCH-25.1* MCHC-29.9* RDW-15.0 Plt Ct-364
[**2167-5-17**] 11:00AM BLOOD WBC-7.3 RBC-3.91* Hgb-9.9* Hct-31.7*
MCV-81* MCH-25.3* MCHC-31.1 RDW-15.7* Plt Ct-336
[**2167-5-17**] 11:00AM BLOOD Neuts-73* Bands-16* Lymphs-7* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2167-5-18**] 04:10AM BLOOD Plt Ct-364
[**2167-5-18**] 04:10AM BLOOD PT-13.8* PTT-25.3 INR(PT)-1.2*
[**2167-5-17**] 11:00AM BLOOD Plt Smr-NORMAL Plt Ct-336
[**2167-5-18**] 04:10AM BLOOD Glucose-193* UreaN-24* Creat-0.7 Na-141
K-4.5 Cl-93* HCO3-40* AnGap-13
[**2167-5-17**] 11:00AM BLOOD Glucose-302* UreaN-21* Creat-0.8 Na-136
K-4.4 Cl-88* HCO3-39* AnGap-13
[**2167-5-18**] 11:52AM BLOOD Type-ART pO2-83* pCO2-91* pH-7.30*
calTCO2-47* Base XS-14 Intubat-NOT INTUBA
[**2167-5-17**] 10:50PM BLOOD Type-ART pO2-78* pCO2-81* pH-7.35
calTCO2-47* Base XS-14
[**2167-5-17**] 08:15PM BLOOD Type-ART pO2-69* pCO2-84* pH-7.34*
calTCO2-47* Base XS-15
[**2167-5-17**] 07:15PM BLOOD Type-ART Temp-37.7 O2 Flow-3 pO2-62*
pCO2-93* pH-7.31* calTCO2-49* Base XS-15 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2167-5-17**] 03:15PM BLOOD Type-ART Temp-37.8 FiO2-35 pO2-60*
pCO2-88* pH-7.33* calTCO2-49* Base XS-15 Intubat-NOT INTUBA
Comment-BIPAP 5/5
[**2167-5-17**] 12:18PM BLOOD Rates-/35 Tidal V-400 PEEP-5 FiO2-35
pO2-57* pCO2-79* pH-7.34* calTCO2-44* Base XS-12 Intubat-NOT
INTUBA
[**2167-5-17**] 11:34AM BLOOD Type-ART Rates-/39 Tidal V-350 FiO2-35
pO2-72* pCO2-102* pH-7.27* calTCO2-49* Base XS-15 Intubat-NOT
INTUBA
[**2167-5-17**] 11:15AM BLOOD Lactate-1.6
[**2167-5-18**] 11:52AM BLOOD Lactate-0.7
CXR
[**2167-5-18**]
In comparison with the study of [**5-17**], there is some increasing
opacification at the left base consistent with atelectasis or
supervening
pneumonia. Hyperexpansion of the lungs is again suggestive of
chronic
pulmonary disease. Small bilateral pleural effusions are again
seen.
[**2167-5-17**]
Within that limitation, there is suggestion of a left basilar
opacity. Small
bilateral pleural effusions are new compared to [**2167-4-15**].
Calcified granulomas
in bilateral lungs are unchanged. The lungs are hyperinflated,
as before. The
cardiomediastinal silhouette, hilar contours, and pulmonary
vasculature are
not significantly changed. Osseous structures are grossly
unchanged including
the old right clavicular fracture and loss of height in mid
thoracic vertebral
body.
IMPRESSION: Limited study as above. Left basilar opacity
suggested
which may represent atelectasis versus pneumonia. There are
small bilateral
pleural effusions, new since [**2167-4-15**]. If feasible, consider PA
and lateral
views in the radiology suite for more sensitive evaluation.
Brief Hospital Course:
This is a 80 yo female with severe COPD, diastolic HF, who
presents with hypoxia and hypercarbia
# Hypoxia/Hypercarbia: COPD exacurbation. Possible causes of
worsening COPD include PNA, URI. Also anxiety plays a big role
in her exacurbations. We treated her with nebs, CTX and
Azithromycin. Also she was given stress dose solumedrol and
transition to prednisone po with 15 day [**Doctor Last Name 2949**]. Ativan was given
every 8 hrs as needed. Initially she was placed on BiPAP but
was able to be weaned from this device. She is a baseline CO2
retainer and her oxygenation goal should be Sat 88-92%. Sputum
and blood cultures were sent and were ngtd on discharge. The
patient is DNR/DNI.
# Diastolic HF: No evidence of CHF exacurbation on this
admissin. We continued home dose lasix.
# DM2: not on home medications; fingersticks here markedly
elevated in the setting of steroid use. We placed her on insulin
sliding scale which should be continued until steroid [**Last Name (un) 10128**] is
completed.
# Depression/Anxiety: continued home meds
Medications on Admission:
Avair diskus 2 pufs daily
COlace 100 mg daily
Combivent 2 puffs QID
Cymbalta 60 mg daily
Duoneb PRN
Fluticasone [**1-2**] sprays 50 mcg
Lasix 20 mg daily
MVI
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-2**] Inhalation Q3H (every 3 hours).
12. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 6 days.
13. Prednisone 10 mg Tablet Sig: ASDIR Tablet PO once a day for
15 days: 60 mg for 3 days, 40 mg for 3 days, 20 mg for 3 days,
10 mg for 3 days,
5 mg for 3 days, then off.
14. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO three times a day
as needed for anxiety.
15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
16. Fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
Inhalation twice a day.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
COPD exacurbation
Discharge Condition:
Good, Sa O2 92% 2 lt, comfortable
goal SaO2 88-92%
Discharge Instructions:
You were admited with worsening of your COPD. We treated you
with antibiotics, nebulizer treatments and steroids.
Please call your regular doctor or return to the ED if you have
shortness of breath, chest pain, palpitations, wheezing worsened
edema or any other concerns
Followup Instructions:
Please follow up with your regular doctor within 10 days.
[**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 2205**]
Completed by:[**2167-5-18**]
ICD9 Codes: 4280 | [
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train_43524 | completed | 93af0464-c209-4fbf-8fe5-bbe20fe25021 | Medical Text: Admission Date: [**2137-5-14**] Discharge Date: [**2137-5-20**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 5134**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 89307**] is an 87y/o gentleman with HTN and CAD s/p stents,
MI x3 (last one medically managed), who presented to an OSH s/p
fall and was transferred here for further management. He had
subbed his toe and fell face-first to the ground. He denied
LOC, changes in vision, nausea or vomiting. He was found to
have right frontal SAH, C1 and type 2 dens fracture, frontal
bone and superior orbital fracture.
Upon transfer to [**Hospital1 18**], vital signs were: afebrile, HR 77, BP
147/68, RR 18, SaO2 97% 2L. He was alert and interactive,
complaining of neck pain. He was admitted to a surgical floor
but was quickly found to be in respiratory distress with O2 sat
80% RA, 93% face tent and 5L NC. He was given Lasix 20mg IV and
was transferred to the Trauma Surgery ICU for management of his
heart failure.
Past Medical History:
Hypertension
Hypercholesterolemia
CAD s/p MI x3 with 3 stents in place
TIAs in the past; right leg drags slightly
Fire burn to back recently, s/p skin grafting at OSH (donor site
was right thigh)
GERD
s/p appendectomy
Depression
Right rotator cuff tear
Social History:
Family: he is a widow and lives alone. His daughter [**Name (NI) **]
(healthcare proxy) lives in [**Location **] but visits frequently. He has a
health aid [**Doctor First Name 5321**] who checks in on him 3-4 times a week.
Tobacco: non-smoker
EtOH: none
Illicits: none
Family History:
NC
Physical Exam:
ADMISSION EXAM:
VITALS: T: afebrie, BP:147/68, HR:77, R 18, O2Sat: 97% 2L NC
GEN: A&O x 3
HEENT: large right frontal ecchymosis, with swelling of right
eye. No scleral bleeding, EOMs intact, PERRLA.
CV: RRR, No M/G/R
NECK: Hard cervical collar in place, no point tenderness on
palpation.
PULM: Diffuse rales throughout all fields with crackles at bases
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: Right thigh is dressed, this was the donor site for his
skin
graft. No LE edema, LE warm and well perfused
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 2-----------
Left 2-----------
Proprioception intact
Toes downgoing bilaterally
.
DISCHARGE EXAM:
VS: Tm/Tc 99.2/96, BP 142/72 (118-132)/(60-70), HR 88 (75-88),
RR 18, SaO2 99%RA
In/Out: 400cc/800cc
General: Alert, oriented to self, city, month/year, no acute
distress
HEENT: hematoma on right forehead with periorbital ecchymosis
and conjunctival hemorrhage
Neck: in collar, unable to assess JVP
CV: normal S1 + S2, no murmur
Pulm: clear to auscultation superiorly, crackles at bases
Pertinent Results:
ADMISSION LABS:
[**2137-5-13**] 07:24PM BLOOD WBC-15.1* RBC-3.22* Hgb-10.0* Hct-28.9*
MCV-90 MCH-31.0 MCHC-34.5 RDW-14.4 Plt Ct-228
[**2137-5-13**] 07:24PM BLOOD Neuts-84.6* Lymphs-12.5* Monos-2.4
Eos-0.4 Baso-0.2
[**2137-5-13**] 07:24PM BLOOD PT-13.7* PTT-21.8* INR(PT)-1.2*
[**2137-5-13**] 07:24PM BLOOD Glucose-192* UreaN-52* Creat-1.7* Na-137
K-4.7 Cl-102 HCO3-22 AnGap-18
[**2137-5-14**] 11:20AM BLOOD ALT-20 AST-42* CK(CPK)-251 AlkPhos-54
TotBili-0.4
[**2137-5-13**] 07:24PM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
PERTINENT LABS:
[**2137-5-13**] 07:24PM BLOOD CK-MB-5
[**2137-5-13**] 07:24PM BLOOD cTropnT-0.06*
[**2137-5-14**] 11:20AM BLOOD CK-MB-12* MB Indx-4.8 cTropnT-0.24*
[**2137-5-14**] 09:23PM BLOOD CK-MB-8 cTropnT-0.30*
[**2137-5-15**] 03:12AM BLOOD CK-MB-7 cTropnT-0.37*
[**2137-5-16**] 06:55AM BLOOD CK-MB-4 cTropnT-0.55*
[**2137-5-17**] 08:00AM BLOOD CK-MB-4 cTropnT-0.78*
DISCHARGE LABS from [**5-19**]:
Creatinine 1.7
WBC 7.7
Hb/Hct 9.5/27.8
Plt 230
CT CHEST/ABDOMEN/PELVIS W/O CONTRAST [**2137-5-13**]
1. Anterior wedge deformity of T1 of unknown acuity with
widening of the
anterior disc space of C6/7. This can be further assessed at the
time of
C-spine MRI.
2. No acute fractures in the remainder of the thoraco-lumbar
spine.
3. Cholelithiasis without cholecystitis.
4. Diverticulosis without diverticulitis.
5. Diffuse ground glass pulmonary opacities in setting of
effusions and
cardiomegaly may be due to pulmonary edema.
6. Secretions within the left mainstem bronchus.
CT C-SPINE W/O CONTRAST [**2137-5-13**]
1. Fractures of C1 and the dens of C2 as described above with
marked
narrowing of the spinal canal at that level and adjacent
hematoma. MRI is
recommended for further evaluation of the spinal cord.
2. Anterior compression deformity of T1 with possible oblique
fracture of
unknown acuity. No retropulsion. This can be further assessed at
the time of MRI.
3. Widening of the anterior intervertebral disc space at C6-7.
Assessment for ligamentous injury at this level can be assessed
on MRI.
EKG [**2137-5-14**]
Sinus rhythm. Probable intra-atrial conduction delay. ST-T wave
changes with prolonged QTc interval are non-specific but
clinical correlation is suggested. No previous tracing
available for comparison
MRI C-SPINE W/O CONTRAST [**2137-5-14**]
1. Type 2 odontoid dens fracture with distraction and angulation
causing mild canal narrowing without evidence of a cord
contusion or intraspinal hematoma.
2. C1 fracture is better demonstrated on the recent CT study.
3. Widening of the anterior intervertebral disc space at C6-7
suggests
distraction without convincing evidence of an anterior
longitudinal ligament injury.
4. Increased T2 and STIR signal at the superior aspect of C7
vertebral body
suggests fracture versus bone contusion.
5. Anterior wedge compression deformity of T1 vertebral body.
6. Widening and distraction of the left C6-7 facet joint with
fluid.
Images are degraded by motion artifact, failed to correct on
multiple
sequences.
CT HEAD W/O CONTRAST [**2137-5-14**]
1. Enlarging right frontal hemorrhagic contusion, with increased
local mass
effect, but no shift of normally midline structures.
2. Mild right convexity subarachnoid hemorrhage, slightly
increased.
3. Moderate hematoma in the right frontal scalp.
4. 1.4 cm nodular lesion in the right suboccipital scalp. Please
correlated
with physical exam.
CXR [**2137-5-14**]
Severe pulmonary edema with moderate cardiomegaly.
TRANSTHORACIC ECHO [**2137-5-15**]
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 20-25 %). The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severe global LV hypokinesis. Only the lateral wall
has relatively preserved function. Dilated and depressed RV with
moderate tricuspid regurgitation and moderate pulmonary
hypertension. Mild aortic regurgitation.
CXR [**2137-5-15**]
As compared to the previous radiograph, there is minimal
improvement of the still extensive pulmonary edema. The lung
volumes have
slightly increased. Newly appeared focal parenchymal opacities
suggesting
pneumonia. No pleural effusions. Unchanged size and shape of the
cardiac
silhouette. Unchanged appearance of the mediastinal structures.
Old left rib fractures. Unchanged interposition of colon between
liver and
the abdominal wall.
CT HEAD W/O CONTRAST [**2137-5-15**]
1. Unchanged appearance of a post-traumatic large right frontal
parenchymal
hematoma, with minimal leftward subfalcine herniation.
Blood/fluid levels
within this lesion are somewhat unusual, in the absence of
therapeutic
anticoagulation or known coagulopathy.
2. Slight increase in intraventricular blood, which may reflect
redistribution.
3. Right frontal and parietal subarachnoid blood is less
conspicuous.
4. No new mass effect.
5. Improved subgaleal hematoma and soft tissue swelling
overlying the right
calvaria.
COMMENT: Given the large size of this "lobar" hemorrhage, the
presence of
immediately-overlying subarachnoid blood and blood/fluid levels,
a
contribution of underlying amyloid angiopathy cannot be excluded
(in a patient of this age).
SPEECH AND SWALLOW EVALUATION/NOTE [**2137-5-17**]
SUMMARY:
Mr. [**Known lastname 89307**] presented with a mild oral and mild-moderate
pharyngeal dysphagia with reduced oral control, swallow delay
and reduced laryngeal valve closure. The presence of the hard
cervical collar is also impacting his positioning during meals
and he is aspirating both thin and nectar thick liquids, even
with the use of compensatory techniques. While the risk can be
reduced, I was unable to eliminate aspiration on this exam.
While aspiration before and during the swallow is likely new, he
was also found with significant retention of barium in the
esophagus (question of a diverticulum) with backflow to the
pharynx after the swallow. He is at high risk for intermittent
aspiration from below and this is likely a baseline issue he has
dealt with for some time.
As such, even if he were to be NPO with tube feeds while the
collar is in place, his dysphagia and risk for aspiration will
not be fully resolved when the collar is off. With that being
said, the risk for aspiration should be significantly reduced
once the collar is off and it would return to his baseline
dysphagia which he has likely been dealing with for some time.
As such, suggest additional discussions regarding options and
goals
of care. I do fel his risk for developing PNA on a PO diet is
high, given the amount of aspiration seen today.
FOIS rating of 1.
RECOMMENDATIONS:
1. Suggest additional discussions regarding goals of care, as
there are no consistencies that are free from aspiration
2. If he agrees to accept the risks of aspiration, suggest a PO
diet of nectar thick liquids and moist, ground solids with the
following precautions:
a) sit so your neck / cervical collar is as close to 90
degrees as possible (not the back of the bed or chair)
b) take small, single sips of liquid
c) follow each bite with a sip of liquid
d) sit upright for at least 30 minutes after PO intake
e) meds crushed with purees, followed by a sip of liquid
3. TID oral care
4. If the pt wishes to pace a feeding tube, would suggest a
repeat video swallow when cervical collar can be removed
5. We are happy to discuss the results with pt's family or
attend
a family meeting if helpful. Please page with any questions.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Mr. [**Known lastname 89307**] is an 87y/o gentleman with HTN, HLD, CAD s/p MI's,
TIA's with leg weakness who was transferred to [**Hospital1 18**] after
presenting to an OSH with a mechanical fall associated with
multiple injuries. During his stay, he was evaluated by
Neurosurgery and did not require surgical intervention, but he
does need to wear a hard cervical collar for three months. His
stay was complicated by CHF exacerbation, for which he was
diuresed. He was discharged to rehab.
.
ACTIVE ISSUES:
.
#. s/p fall with trauma: No surgical intervention needed.
He has a right frontal SAH, R IPH, R subgaleal hematoma, C1 and
type 2 dens fracture, frontal bone and superior orbital
fracture. He was evaluated by Plastic Surgery and Neurosurgery
and did not require surgical intervention. He needs to wear a
hard cervical collar for at least 3 months ([**Date range (1) 89308**])-the
collar is not comfortable but must be worn at all times and must
not be loosened or allowed to slip up over his face. He was
started on Dilantin 100mg PO TID for seizure prophylaxis and is
on Q6H neuro checks. He will need to follow up with
Neurosurgery in one month for repeat head/neck CT.
.
#. Systolic CHF exacerbation: resolved.
He had a brief O2 requirement and CXR showed florid volume
overload, possibly from volume resuscitation. He was diuresed
in the Trauma Surgery ICU on a Lasix drip for one day, and then
he was able to be transferred to the Medicine floor where he was
managed further with Lasix boluses. A few days later he was
weaned back to room air and his lungs were clear. From then on,
he was noted to be euvolemic despite not being on a maintenance
dose of Lasix (perhaps due to decreased PO intake, as noted
below) so diuretics were not continued. Given that his EF is
20-25% it will be important to monitor his volume status to
ensure that he does not develop pulmonary edema if his oral
intake increases during rehab - he may need to be started on
daily Lasix (his prior home dose was 40mg PO daily). He will
follow up with his Cardiologist, Dr. [**Last Name (STitle) 8421**].
.
#. Afib: paroxysmal, rate controlled.
Per his daughter, he has a history of "irregular heartbeat" and
was on Coumadin at some point but it was stopped. His CHADS2 is
5 but risk of bleed is too high given his brain bleeds. He did
have a few episodes of RVR with rate up to the 140's but he was
hemodynamically stable through these and his rate was controlled
with extra Lopressor IV. When he was restarted on his home beta
blocker regimen, Metoprolol 25mg TID, he was stable. At the
time of discharge he was in normal sinus rhythm. Once he
recovers from his head bleeds, he may be considered for Coumadin
therapy. For now he will continue on aspirin (currently on) and
plavix (to be started [**5-21**] - see below) for thromboembolic
prophylaxis. He will follow up with his Cardiologist.
.
#. Witnessed Aspiration: per Speech and Swallow (appreciate
recs) and video swallow, it is due to a combo of neck collar and
underlying diverticulum. Patient understands risk of aspiration
and chooses to eat, per family meeting [**2137-5-17**] with him and his
daughter [**Name (NI) **]. Declines PEG tube. He was given a diet of
nectar thick liquids and moist ground solids, with no episodes
of aspiration or desaturation. He takes meds crushed with
applesauce.
.
# Hypertension: he was normotensive and in fact required
decrease in the doses of some of his medicines. Hydralazine was
discontinued and his dose of Isosorbide dinitrate was decreased.
He was continued on Lisinopril for cardiac protection. SBP
ranged from 100-130 at the time of discharge. He will follow up
with his Cardiologist.
.
#. h/o CAD with elevated cardiac biomarkers: possibly
represented demand ischemia.
His troponins were trended and he likely did have demand
ischemia at the time of CHF exacerbation. He was continued on
ASA, beta blocker, statin, ace-inhibitor. Plavix needed to be
held for 1 week per Neurosurgery but should be restarted on
[**2137-5-21**] (one day after discharge).
.
INACTIVE ISSUES:
.
#. Elevated creatinine: acute on chronic kidney disease,
resolved.
One month prior to admission, he was noted to have Cr 2 but this
is likely not his baseline. Upon admission, his Cr was 1.6 and
rose to 1.8 in the setting of diuresis (likely prerenal kidney
injury) but decreased to 1.7 at the time of discharge.
.
#. Anemia: iron deficiency, stable.
Iron studies consistent with iron deficiency. Hct was stable
near 28 throughout admission. He should follow up as an
outpatient with regards to a screening colonoscopy and the
possibility of iron supplementation.
.
#. Burn injury: stable.
He has burns on his back from a kitchen accident and he is s/p
grafting. One of the areas is not well healed; Wound Care
recommendations were followed and he will need wound care during
rehab. Recs were provided with his discharge paperwork.
.
#. GERD: stable.
He was continued on Omeprazole.
.
#. Depression: he was in surprisingly good spirits during this
admission.
He was continued on Paxil.
.
TRANSITIONAL ISSUES
.
#. Prophylaxis: SC Heparin
#. Code Status: DNR/DNI
#. Healthcare Proxy: [**First Name5 (NamePattern1) **] [**Known lastname 89307**] (daughter) [**Telephone/Fax (1) 89309**]
Medications on Admission:
Aspirin 325mg daily
Plavix 75mg daily
Metoprolol 25mg TID
Lisinopril 2.5mg daily
Lovastatin 40mg daily
Fish oil 1200mg daily
Omeprazole 40mg daily
Isosorbide dinitrate CR 40mg TID
Hydralazine 25mg [**Hospital1 **]
Lasix 40mg daily
Paxil 60mg daily
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg
PO Q8H (every 8 hours).
11. hydromorphone 2 mg Tablet Sig: 2-4 mg PO Q4H (every 4 hours)
as needed for pain.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Intracerebral hemorrhage
Multiple fractures
Congestive heart failure exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **] CARDIOLOGY ASSOCIATES
Address: [**Last Name (un) **]. STE# 206, [**Hospital1 420**],[**Numeric Identifier 26668**]
Phone: [**Telephone/Fax (1) 45578**]
When: [**Last Name (LF) 766**], [**6-3**], 1:15PM
Department: RADIOLOGY
When: WEDNESDAY [**2137-6-19**] at 8:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2137-6-19**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 4280, 4019, 2720, 311 | [
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train_43578 | completed | f7052d8e-fac0-44a7-85bb-a523edfee2c5 | Medical Text: Admission Date: [**2139-7-26**] Discharge Date: [**2139-8-9**]
Date of Birth: [**2060-11-20**] Sex: F
Service: [**Last Name (un) **]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Subdural hematoma s/p fall
Major Surgical or Invasive Procedure:
four vessel angiography
History of Present Illness:
78 yo F s/p fall found down, pt denies LOC . on XRAY has a C7
cervical fracture, head CT with small L SDH. Neurologically
intact, no focal weakness, numbness, parasthesias
Past Medical History:
glaucoma, hydrocephalus, R total knee replacement
Social History:
unknown
Family History:
unknown
Physical Exam:
99 127/52 91 18 100% on nasal canula
A/O x 3
PERRL
RRR
CTA b/l
ABD soft, nt/nd
ext warm, no edema
neuro intact
Pertinent Results:
four vessel angio
with Right MCA acute occlusion
Brief Hospital Course:
Pt admitted with C7 fracture and L SDH after 4 vessel angio
found to have R MCA occlusion and will need intervention.
Medications on Admission:
toprol
mvi
aricept
Discharge Medications:
protonix
metoprolol
hydralazine
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute Right MCA Occlusion/Stroke
L Sub dural hematoma
C7 fracture
Glaucoma
?Hydrocephalus
R total Knee replacement
hypertension
dementia
Discharge Condition:
critical
Discharge Instructions:
bedrest
venodyes
pul toilet
npo
ivf
C collar on
neuro checks
Followup Instructions:
f/u with interventional neuroradiology
Completed by:[**0-0-0**]
ICD9 Codes: 4019 | [
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train_47657 | completed | e932f508-02d9-4f16-bddb-4aa8c2b9db0c | Medical Text: Admission Date: [**2143-4-4**] Discharge Date: [**2143-4-8**]
Service: CARDIOTHORACIC
Allergies:
Ibuprofen / Oxycodone Hcl/Acetaminophen / Aspirin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain and dyspnea on exertion.
Major Surgical or Invasive Procedure:
Aortic valve replacement(27-mm [**Company 1543**] mosaic ultra aortic
valve bioprosthesis) and Coronary artery bypass grafting
x3(LIMA-LAD,SVG-diag 1,SVG-diag 2),Patch bovine pericardial
aortoplasty.
History of Present Illness:
This is a 87 year old male with known severe aortic stenosis and
multivessel
coronary artery disease orginally seen 3 years ago. She states
over the last 5 months he has developed chest pain and dyspnea
on exertion. He was referred for surgical evaluation and was
admitted now for this.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
h/o bleeding gastric ulcer
h/o bleeding cecal arteriovenous malformation
Hypertension
Dyslipidemia
Diverticulosis
Rheumatic fever
Pulmonary Hypertension
Axillary Adenopathy
Cholelithiasis
Social History:
Lives alone. Two daughters. Denies tobacco and EtOH.
Family History:
non contributory
Physical Exam:
Admission:
Pulse: 54 Resp: 16 O2 sat: 99%
B/P Right: 146/51 Left: 137/79
Height: 5'8" Weight: 179
General: well-developed obese elderly male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] +Murmur [**2-2**]
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right/Left: -
Pertinent Results:
[**2143-4-8**] 04:45AM BLOOD WBC-12.1* RBC-3.35* Hgb-9.0* Hct-27.9*
MCV-83 MCH-26.9* MCHC-32.3 RDW-16.2* Plt Ct-314
[**2143-4-7**] 03:40AM BLOOD WBC-14.6* RBC-3.23* Hgb-9.4* Hct-26.6*
MCV-82 MCH-29.0 MCHC-35.2* RDW-16.6* Plt Ct-243
[**2143-4-4**] 12:45PM BLOOD WBC-25.5*# RBC-2.50*# Hgb-6.7*#
Hct-21.0*# MCV-84 MCH-26.7* MCHC-31.8 RDW-16.2* Plt Ct-311
[**2143-4-4**] 02:35PM BLOOD PT-13.8* PTT-36.9* INR(PT)-1.2*
[**2143-4-8**] 04:45AM BLOOD UreaN-20 Creat-1.0 K-3.9
[**2143-4-7**] 03:40AM BLOOD Glucose-104* UreaN-22* Creat-1.1 Na-135
K-3.7 Cl-101 HCO3-27 AnGap-11
[**2143-4-4**] 02:35PM BLOOD UreaN-14 Creat-0.8 Cl-112* HCO3-23
[**2143-4-8**] 04:45AM BLOOD Mg-2.1
Brief Hospital Course:
Following admission he was taken to the Operating Room where
revascularization was accomplished. See operative note for
details. He weaned from bypass on Epinephrine
and Propofol. He remained stable, weaned from pressors and the
ventilator easily and was begun on beta blockers and diuretics
as usual. He did have brief rapid atrial fibrillation which
converted to sinus with Amiodarone.
Ph6ysical therapy worked eith him for mobility and strength. He
was felt to be an appropriate candidate for rehabilitation and
arrangemnents were made for this. he was transferred to
[**Hospital 71164**] Rehab on POD 4. Wounds were clean and healing well.
Discharge instructions, medications and follow up were sent with
the patient.
Medications on Admission:
Lipitor 40mg qd
Hydrocodone-Acetaminophen 5-500mg q6 prn
Omeprazole 40mg qd
Diovan 80mg qd
Colace 100mg [**Hospital1 **]
Fish oil
Vitamin D
Nystatin cream
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Amiodarone 200 mg Tablet Sig: see below Tablet PO see below
for 4 weeks: two tablets twice daily for two weeks, then one
tablet twice daily for two weeks, then stop.
12. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 6930**] Skilled Nursing and Rehabilitation Center - [**Hospital1 6930**]
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
h/o Bleeding gastric ulcer
h/o bleeding cecal arteriovenous malformation
Hypertension
Dyslipidemia
Diverticulosis
Rheumatic fever
Pulmonary Hypertension
Axillary Adenopathy-benign
Cholelithiasis
Discharge Condition:
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions: clean and dry
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Surgeon: Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on Tuesday, [**5-7**] at 1:30pm
Please call to schedule appointments with:
Primary Care: Dr.[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 19980**]in [**12-1**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] in [**12-1**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2143-4-8**]
ICD9 Codes: 4019, 2724, 4168 | [
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train_47879 | completed | a5cb9dc8-7be4-46ab-b24e-c4dd43874395 | Medical Text: Admission Date: [**2165-7-10**] Discharge Date: [**2165-7-19**]
Date of Birth: [**2126-9-22**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: This is a 39-year-old male who
entered via the Emergency Room after being in an altercation
and being struck in the head and face with a blunt object.
He had obvious facial trauma and required intubation at the
time of presentation.
PAST MEDICAL HISTORY: Unremarkable.
HOSPITAL COURSE: The patient underwent extensive radiologic
investigation. A CT scan of the head showed no intracranial
injury. He had a complex facial fracture involving the left
maxillary sinus and left mandible. Plain films of the neck
showed a loss of C6 body height, however, follow-up CT scans
of the neck in an MRI scan of the neck failed to show any
significant injury. A CT scan of the abdomen was
unremarkable. He had no extremity injuries. He was
initially maintained in the Intensive Care Unit. There, he
ultimately was extubated. On [**7-17**], he went to the
Operating Room where he underwent open reduction and internal
fixation of the mandibular fracture by the oral maxillary
Facial Surgery Service. He was then discharged to home two
days later.
DISPOSITION: To home.
OPERATIONS PROCEDURES: [**2165-7-17**] open reduction and
internal fixation of mandible fracture.
CONDITION ON DISCHARGE: Improved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2166-2-4**] 03:04
T: [**2166-2-4**] 16:36
JOB#: [**Job Number **]
ICD9 Codes: 5715 | [
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train_47433 | completed | 0202e0e2-9254-4241-806a-dc6520ee8816 | Medical Text: Admission Date: [**2145-6-20**] Discharge Date: [**2145-6-25**]
Date of Birth: [**2103-7-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
New Onset seizure
Major Surgical or Invasive Procedure:
[**6-23**]: Right Craniotomy for Mass Resection
History of Present Illness:
Patient is a 41F who is transferred to [**Hospital1 18**] after being found
to have a new right parietal brain mass. She was apparently
shopping at [**Company **] on [**6-19**], when at about 5pm she was observed
to have a seizure, and was taken to the hospital
Past Medical History:
None
Social History:
+smoking
Family History:
non-contributory
Physical Exam:
On admission:
T:95.7 BP:110/68 HR:90 R 18 O2Sats 100
Gen: comfortable, NAD.
HEENT:atraumatice Pupils:3 to 2 EOMs full
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-13**] throughout. No pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
Exam on Discharge:
Patient is neurologically stable.
Oriented x 3. PERRL, EOMs intact.
Full strength and sensation throughout.
No drift.
Incision clean, dry, intact.
Pertinent Results:
Labs on Admission:
[**2145-6-19**] 11:00PM BLOOD WBC-9.0 RBC-3.77* Hgb-11.3* Hct-33.1*
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.7 Plt Ct-328
[**2145-6-19**] 11:00PM BLOOD Neuts-75.4* Lymphs-20.2 Monos-2.7 Eos-1.6
Baso-0.1
[**2145-6-19**] 11:00PM BLOOD Glucose-120* UreaN-19 Creat-0.9 Na-145
K-4.3 Cl-114* HCO3-21* AnGap-14
[**2145-6-20**] 08:35AM BLOOD Phenyto-13.2
Imaging:
Head CT [**6-19**]:
FINDINGS: There is a 2.8 x 3.2 x 2.3 cm mildly hyperdense right
frontal
lesion near the vertex with a hypodense interior that avidly
enhances. There does not appear to be cortical erosion of bone
or hyperostosis. There is no pronounced perilesional edema. No
other mass is seen. There is small calcification in the left
temporal lobe. There is no shift of normally midline structures.
Mastoid air cells are clear. Visualized paranasal sinuses are
clear. The orbits appear unremarkable.
IMPRESSION: Right frontal enhancing mass with necrotic interior
most likely a brain neoplasm. Consider MR for further
characterization.
CT Torso [**6-20**]:
CT CHEST: The airways are patent up to subsegmental level. There
are no
concerning airspace opacities, or pulmonary nodules. There is no
pleural
effusion. There are no pathologically enlarged lymph nodes in
the mediastinum, hilum, or axilla according to CT size criteria.
There are subcentimeter lymph nodes in the axilla; however do
not meet the CT criteria for pathological enlargement. Calcified
nodes are also seen in the mediastinum. The heart size is
normal. There is no pericardial effusion.
CT ABDOMEN: The liver, pancreas, spleen appear normal. The
adrenal glands
are normal. The kidneys enhance symmetrically and excrete
contrast
symmetrically with bilateral hypodensities too small to
characterize, likely small renal cysts. The gallbladder appears
normal with gallstones within. There are no pathologically
enlarged lymph nodes in the retroperitoneum or mesentery. The
loops of small and large bowel appear normal. The stomach
appears normal. There is no free fluid. There is no free air.
CT PELVIS: The urinary bladder and ureters appear normal. The
sigmoid and
loops of small bowel within the pelvis appear normal. There is
no free fluid in the pelvis. There are no enlarged lymph nodes
in the pelvic or inguinal area according to CT size criteria.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
seen in the bones.
IMPRESSION:
1. No evidence of primary tumor in the CT torso.
2. Cholelithiasis without evidence of cholecystitis.
MRI Head [**6-22**]:
FINDINGS: There is a 2.7 cm round circumscribed extra-axial mass
at the right vertex, depressing the paracentral lobule
inferiorly. There is mild
associated vasogenic edema in the adjacent frontal and parietal
lobes. The
mass demonstrates isointensity on the pre-contrast T1-weighted
images, mild hyperintensity on T2-weighted images, neither fast
nor slow diffusion, and predominantly solid enhancement with a
small non-enhancing center on the postcontrast T1-weighted
images. A small portion of the non-enhancing center demonstrates
low signal on the gradient-echo images without evidence of
blooming, which is somewhat more likely to represent
calcification rather than blood products. Faint hyperdensity
within the mass on the preceding CT scan is compatible with
either calcification or blood products. Overall, the mass is
most consistent with a meningioma.
No other intra-axial or extra-axial masses are seen. The
ventricles are
normal in size and configuration. There is no acute infarction.
The major
arterial flow voids are unremarkable.
IMPRESSION: 2.7 cm extra-axial mass at the right vertex, most
likely a
meningioma, with mild vasogenic edema in the paracentral lobule.
Brief Hospital Course:
Patient is a 41F who is transferred from OSH after
identification of new right parietal mass in the setting of
seizure. She was started on antiepileptic medication, and
admitted to the neurosurgery floor for additional work up. The
patient went to the OR for craniotomy on [**6-23**] and the procedure
went well without complications. She went to the ICU afterwards
for Q 1 hour neuro checks. The patient was neurologically stable
and was transferred to the neurosurgery floor on [**6-24**]. She had a
post-op MRI which showed expected surgical changes without
evidence of new infarct. The patient worked with physical
therapy and occupational therapy who felt that she was safe to
be discharged to home on [**6-25**]. The patient was neurologically
stable and was given instructions to follow-up in the Brain
[**Hospital 341**] Clinic.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): continue until follow up.
Disp:*90 Capsule(s)* Refills:*1*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO three
times a day: take 3 tid x 1 day, then 2 tid x 1 day, then 1 tid
x 1 day, then stop medication.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Rt. Parietal Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions/Information
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures have been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
??????You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**6-18**] days for removal of your
sutures. This appointment can be made with the Nurse
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic. [**Name6 (MD) 640**] [**Name8 (MD) 15756**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2145-7-19**] 9:30 am. The
Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], in
the [**Hospital Ward Name 23**] Building. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2145-6-25**]
ICD9 Codes: 3051 | [
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train_47478 | completed | 16e6e801-bccc-4d2a-9397-01b15ff95f92 | Medical Text: Admission Date: [**2145-8-1**] Discharge Date: [**2145-8-11**]
Date of Birth: [**2073-12-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Nsaids
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Intubation, tunnelled hemodialysis catheter placement
History of Present Illness:
71 y.o. male NH resident with h/o DM, ESRD, [**Hospital 3593**] transferred from
[**Hospital **] Hospital [**2145-8-1**] where he presented with L sided
weakness after dialysis. [**Name6 (MD) **] [**Name8 (MD) **] RN upon return from HD, the pt
refused his dinner, was incontinent of urine, conused. T101.1,
128, 74/56 and 92% on RA. He was then transferred to [**Hospital **]
Hospital, where T 103.1, bp 147/55. He then became hypotensive
to 92/42, AT OSH, Urine culture, blood cultures drawn, X ray,
and head CT performed and he received NS and tylenol. He was
noted to be unable to lift left arm or squeeze with left hand
and c/o LLQ pain. He was then transferred to [**Hospital1 18**] per family
request. In the ED here, he received 8 L IVF, vancomycin,
levofloxacin, and metronidazole prior to admission to the ICU
for presumed sepsis. In ED head CT (-) for acute change, Abd CT
(-).
*
Following MICU admission, pt was continued on levo/flagyl/vanco.
On [**8-1**] a.m., he became acutely SOB, ABG c/w hypercarbic
respiratory failure, at which time pt was intubated and started
on levophed for blood pressure support. Blood cultures from [**8-1**]
grew [**3-8**] S. aureus (sensitivities pending), at which time his
abx were changed to vanco/gent. He was extubated the evening of
[**2145-8-1**] and his tunnelled dialysis cathter was removed [**8-2**] a.m.
He was transferred to the medical floor following verification
of hemodynamic stability.
Past Medical History:
1) Diabetes mellitus, c/b Diabetic neuropathy, nephropathy
2) End-stage renal disease on hemodialysis- new catheter on
[**2145-7-13**]
3) Coronary artery disease s/p CABG [**2133**]
- [**7-7**] PMIBI: severe fixed inferior perfusion defect, partially
reversible lateral defect EF 18%
- [**7-7**] TTE: LA mod dil, RA mildly dil, inferior akinesis and
severe anteroseptal and mid to distal inferolateral hypokinesis.
EF 30%
4) Hypertension.
5) History of supraventricular tachycardia.
6) History of L pontine CVA in [**2143-7-5**]- head MR [**First Name (Titles) **] [**Last Name (Titles) 4579**]d moderate stenosis in the mid-basilar artery region
-p/w L sided weakness.
7) History of chronic anemia.
8) Depression
9) h/o Klebsiella UTI
Social History:
Resident of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Has two sons. > 100 pk yr history; quit
2 years ago. H/o heavy EtOH use but has quit (unable to state
when he quit and how much he used to drink). Pt is unable to
state when he quit and how much he used to drink.
Family History:
Father and mother had DM. Cannot recall what they died of.
Physical Exam:
Tc 98.9, Tm 99.8, pc 90, pr 90s-110s, bpc 121/88, bpr
100s-130s/40s-50s, resp 11, 98% 2L NC
Gen: chronically-ill appearing, elderly male, A&OX3, NAD
HEENT: anicteric, pale conjunctiva, OMMM, OP clear, neck supple,
no LAD, JVP ~ 11 cm.
Cardiac: distant heart sounds, S1, S2, II/VI SM at apex, no R/G
Pulm: Carckles at bases bilaterally
Abd: NABS, soft, NT/ND, no HSM
Extremities R AKA, L BKA, Stage I sacral decubitus, warm with
good cap refill
Neuro: (+) left face droop, otherwise CN II-XII grossly intact
and symmetric bilaterally, 4+/5 strength throughout, symmetric
bilaterally.
Pertinent Results:
[**2145-8-2**]
wbc 8.5, Hgb 85, HCT 27.9 (from 24.7), plt 113 MCV 106, RDW 17.2
Na 141, K 3.8, Cl 107, HCO3 23, BUN 24, Cr 3.2, glc 216 AG 11,
MG 1.3 (repleted)
lactate 1.9 (from 4.1)
.
[**2145-8-1**]
PT 14.9, INR 1.5, PTT 37.7 FBG 224
Brief Hospital Course:
1) S. aureus bacteremia: The patient was admitted directly to
the MICU from the ED with the diagnosis of sepsis. He required
a brief period of intubation and blood pressure support, but was
quickly weaned off of the ventilator. Vancomycin and Gentamycin
were started, with renal dosing. The left subclavian
hemodialysis catheter was removed, and prurulent drainage was
visualized during removal. A temporary right IJ was inserted
for central venous access. The patient was then transferred to
the medical floor for further care. A temporary hemodialysis
catheter was placed in a left groin location. Surveillance
cultures were drawn, revealing [**12-8**] positive for s. aureus, then
0/4 and 0/4 on subsequent days. Infectious disease consult was
obtained. A TTE and TEE were both performed and were negative
for vegetations. Bilateral subclavian ultrasounds were
performed, revealing no abscesses, but the right side was
notable for a non-occlusive thrombus in the R subclavian. For
this reason, the decision was made to continue vancomycin
treatment for 4 weeks, with trough goal between 15-20.
Gentamycin was stopped.
.
2) CAD: An initial EKG performed on admission revealed ST
depressions in leads V4-V6. Cardiac enzymes were obtained and
revealed no elevations in troponins x3. The patient was
continued on his statin and Plavix, but due to his sepsis his
beta-blocker was held until he was transferred back to the
medical floor. He was then started on low dose metoprolol,
which can be titrated up as his BP increases.
.
4) L sided weakness: The patient experienced a worsening of his
left sided previous CVA symptoms in the context of his
infected/septic state. These symptoms improved with treatment
of the infection and the patient had returned to his baseline by
the termination of the hospitalization.
.
5) Hypertension: the patient's lisinopril and B-blockers were
both held on admission secondary to hypotension. Once he had
been transferred back to the general medical floor, low dose
lopressor was started to provide some B-blockade in the context
of his CAD. The B-blocker can be titrated up after discharge,
and his lisinopril can be added back as blood pressure
tolerates.
.
6) Anemia: The patient reportedly has a baseline anemia that was
initially worsened during the hospitalization by large volume
fluid resuscitation. Iron studies were sent and were consistent
with anemia of chronic disease. Folate supplementation was also
begun. The patient was noted to have trace guiac positive
stools, which should be followed up with an outpatient
colonoscopy. The patient received 2u PRBC in his first dialysis
following transfer to the general medical floor, with an
appropriate hematocrit increase. Transfusion threshold was set
at 28 due to the patient's coronary artery disease.
.
7) ESRD: Because the patient's permacath HD catheter in the L
subclavian had to be discontinued due to the patient's septic
state, a temporary L groin catheter was inserted for
hemodialysis. Unfortunately, this temporary catheter did not
work for long and had to be removed. Hence, a new tunnelled
right subclavian hemodialysis catheter was placed, with the long
term goal of developing a fistula for continued HD. The patient
was dialyzed every other day, and experienced very few
electrolyte disturbances during his stay. Renal doses of his
medications were given, particularly his antibiotics.
Vancomycin trough levels were drawn just before his dosing at
HD, with goal troughs of 15-20.
.
8) Type II DM: The patient was continued on his home dose of
6units of Lantus insulin qHS, as well as a regular insulin
sliding scale. The patient should be continued on this regimen
as an outpatient in rehab.
.
9) Thrombocytopenia: The patient developed a thrombocytopenia
into the mid 90s following his transfer to the floor. A HIT
antibody was drawn and heparin containing products were
discontinued. The HIT antibody came back negative, but because
of the improvement off heparin products, it was decided to avoid
heparin for the remainder of his stay.
Medications on Admission:
Zestril 2.5 mg po MWF
Protonix 40 mg po qd
Folic Acid T mg po daily
Plavix 75 mg po daily
Iron sulfate 325 qd
Reglan 10 mg po before meals and at bedtime
Vitamin C 500 mg po daily
Lomotil T tab po T, thurs, Sat
Lopressor 25 mg po 3x/day
Lomotil T po T,[**Doctor First Name **], Sat
Lopressor 25 mg po 3x/dy
Nephrocap 100 mg po qd
Atarax 25 mg po 3x daily prn
Novasource, renal 120 cc po tid
Lipitor 20 mg po daily
Percocet 10 mg q 6hrs prn
Tylenol prn
Bisacodyl 10 m supp
Insulin SSI, Lantus 6U SQ qhs
MOM
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) milliliters
PO BID (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY
(Daily).
6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
15. Vancomycin HCl 1000 mg IV Q48H
16. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary Dx:
Sepsis
End-stage renal disease
Diabetes Mellitus
Peripheral Vascular Disease
.
Secondary Dx:
Hypertension
Coronary Artery Disease
Anemia
Depression
Prior stroke
Discharge Condition:
stable
Discharge Instructions:
If you experience fevers, chills, nausea, vomiting, chest pain,
shortness of breath, or any other concerning symptoms, contact
your physician or return to the emergency room.
Followup Instructions:
Please follow up with your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5057**], in the
next two weeks. [**Telephone/Fax (1) 5763**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2145-8-11**]
ICD9 Codes: 3572 | [
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train_47079 | completed | d80d5040-1fd4-44d9-b7c6-ee07da0a53cf | Medical Text: Admission Date: [**2181-2-24**] Discharge Date: [**2181-3-2**]
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous transhepatic cholecystostomy
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] yo female with PMH of AS, DM who was diagnosed
last month with adenocarcinoma of her pancreatic head causing
post-obstructive dilation. She underwent ERCP at that time
after presenting with painless jaundice, which showed a long
stricture in the common bile duct in the region of the
intrapancreatic portion of common bile duct consistent with
pancreatic cancer. Cytology was obtained from this area which
has subsequently returned as positive for adenocarcinoma. A
wall stent was placed for longterm palliation of her obstructive
jaundice.
While she was in the hospital, she also underwent a CT angiogram
of the pancreas with pancreas protocol. This demonstrated a 3
cm mass in the head of the pancreas with obstruction of the
pancreatic duct. The mass encased the gastroduodenal artery, no
definitive metastasis was seen. She was seen by Dr. [**Last Name (STitle) **]
from sugery and was thought not a surgical candidate due to
multiple comorbidities and age.
Today, she presented to [**Hospital3 3583**] with abd pain and fever
and was found to have acute cholecystitis. Her WBC was 26 and
AP 358. She received 3.375 zosyn and fluid before being
transferred to [**Hospital1 18**].
In the ED, initial vs were: 102.4 rectally. HR 140s-160s (afib,
RVR), BP 80s-100s. RR 20. 97% RA. She was reportedly not
responding much, so her head was scanned which was unremarkable.
She had diffuse abd TTP, mostly in RUQ. She was given flagyl
and another dose of zosyn (no cipro b/c of a fluoroquinolone
allergy. She received 4.5L of IVF and tylenol for pain with
improvement in her MS. She was seen by surgery who again felt
she was not an operative candidate in addition to her not
wanting a large surgery, so she was admitted to [**Hospital Ward Name **] ICU
with recommendations to undergo IR-guided percutaneous chole
tube. VS before being sent to ICU: 100.2 rectal. HR 113.
94/59. RR 23. 100% 4L. She has one 18g and one 20g IV. She
is DNR/DNI.
Upon arrival to the ICU, she reports the abdominal pain is
improved but still present. She denies n/v, CP, SOB.
Past Medical History:
hypercholesterolemia
diabetes mellitus type II
glaucoma
aortic stenosis
heel ulcers
Social History:
No tobacco, EtOH, Lives at Life Care Center of [**Location (un) 3320**],
generally uses wheelchair but can use a walker.
Family History:
Noncontributory
Physical Exam:
Vitals: T: 98.5 BP: 89/48 P:113 R: 25 O2: 97% 2L NC
General: Alert but sleepy, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral basal rales. no wheezes, ronchi
CV: tachy, irregular, normal S1 + S2. 2/6 SEM throughout
precordium. no rubs, gallops
Abdomen: soft, non-distended, bowel sounds present. TTP
diffusely, > RUQ. + murphys. no rebound tenderness or
guarding.
Ext: no c/c/e. Large right heel ulcer.
neuro: aox2
Pertinent Results:
Admission labs:
[**2181-2-24**] 08:20PM BLOOD WBC-12.4* RBC-3.87* Hgb-10.4* Hct-32.0*
MCV-83 MCH-27.0 MCHC-32.6 RDW-14.9 Plt Ct-324
[**2181-2-24**] 08:30PM BLOOD PT-15.0* PTT-30.5 INR(PT)-1.3*
[**2181-2-24**] 08:20PM BLOOD Glucose-258* UreaN-54* Creat-2.0*# Na-137
K-4.5 Cl-100 HCO3-23 AnGap-19
[**2181-2-24**] 08:20PM BLOOD ALT-26 AST-27 LD(LDH)-316* AlkPhos-393*
TotBili-1.9*
[**2181-2-25**] 01:40AM BLOOD Albumin-2.7* Calcium-7.3* Phos-3.3 Mg-2.0
[**2181-3-2**] 05:15AM BLOOD WBC-16.4* RBC-3.04* Hgb-8.4* Hct-24.6*
MCV-81* MCH-27.7 MCHC-34.1 RDW-16.0* Plt Ct-498*
.
Discharge labs:
[**2181-3-2**] 05:15AM BLOOD PT-14.9* PTT-29.1 INR(PT)-1.3*
[**2181-3-2**] 05:15AM BLOOD Glucose-75 UreaN-11 Creat-1.0 Na-138
K-3.2* Cl-106 HCO3-25 AnGap-10
[**2181-3-2**] 05:15AM BLOOD ALT-10 AST-16 AlkPhos-280* Amylase-44
TotBili-0.9
[**2181-3-2**] 05:15AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.9
Mg-1.5*
[**2181-2-25**] 9:39 am BILE
.
Microbiology:
**FINAL REPORT [**2181-3-1**]**
GRAM STAIN (Final [**2181-2-27**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2181-3-1**]):
ENTEROBACTER SAKAZAKII. HEAVY GROWTH.
sensitivity testing confirmed by Microscan.
LACTOBACILLUS SPECIES. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROBACTER SAKAZAKII
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
ERCP [**2-6**]:
IMPRESSION: Severe post-obstructive dilatation of the proximal
CBD and intrahepatic biliary ducts with severe narrowing of the
distal CBD with a shelf-like transition concerning for malignant
lesion. Placement of a Wallstent catheter at the site of
narrowing.
.
RUQ U/S [**2181-2-24**]:
IMPRESSION:
1) Distended gallbladder with wall thickening and edema and
pericholecystic fluid consistent with acute cholecystitis.
Irregular mucosa is worrisome for gangrenous cholecystitis.
2) Stable dilatation of the pancreatic duct and intrahepatic
bile ducts. Pancreatic head mass is not well seen. Stent within
the common bile duct.
.
Non-contrast head CT [**2181-2-24**]:
IMPRESSIONS:
1. No acute intracranial abnormality.
2. Chronic small vessel ischemia.
3. Right thalamic lacune
.
CXR [**2181-2-24**]:
IMPRESSION: Patchy bibasilar opacities likely reflect
atelectasis. Low lung volumes. Probable mild volume overload.
.
[**2181-2-26**] LENIS: no DVT.
.
EKG: sinus tach at 110. Nl axis, nl intervals. TWF II/aVF,
q-wave in III/aVF.
Brief Hospital Course:
[**Age over 90 **]F with pancreatic adenocarcinoma with entrapment of the
hepatoduodenal artery and obstruction of the CBD s/p ERCP
stending admitted with cholecystitis and sepsis. She was
initially treated in the MICU and stabilized. She improved from
an infectious point of view. She will need a 14 day course of
antibiotics. She is refusing surgery for her malignancy. She was
DCed back to her [**Hospital1 1501**] with PT, PO cipro for her infection, RN
care of her perc chole, and close follow up. She will follow up
with oncology as an outpatient.
.
# Cholecystitis: Was initally febrile, hypotensive, and with
altered mental status. Not a surgical candidate. Now s/p
percutaneous transhepatic cholecystostomy with ongoing drainage.
Bile culture grew ENTEROBACTER SAKAZAKII with HEAVY GROWTH and
LACTOBACILLUS with SPARSE GROWTH. Initially on
Piperacillin-Tazobactam, but discontinued after sensitivies for
the Enterbacter sp. came back as sensitive to ciprofloxacin.
Conitnue Ciprofloxacin HCl 500 mg PO Q24H for a total of 14 days
to DC on [**2181-3-9**]. Bcx and Ucx negative to date.
.
# Sinus tachycardia with intermitent atrial fibrillation with
rapid ventricular response: LENIs negative for DVT. Started
Metoprolol Tartrate 12.5 mg PO BID with excellent effect.
Holding off on uptitrating dose given aortic stenosis and
tachycardia is the only mechanism to increase cardiac output.
.
# Pancreatic cancer: Not an acute issue. Pt refusing surgery,
which seems reasonable given the clinincal picture. Pt may opt
for palliative chemotherapy. Will F/U as an outpatient with
oncology. Pt. was offered palliative care consult and hospice
care, she stated that she was "not ready for hospice yet", so
this was deferred.
.
# ARF: likely secondary to hypotension. Improving now.
.
# DM: chonic issue, on insulin.
.
# Aortic stenosis: no echocardiogram in the system, unclear
severity. Low dose Bblocker as above.
.
# Glaucoma: Continue Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT
EYE HS, Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H,
Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
Medications on Admission:
MVI
potassium 10 mEQ qday
alphagan P 0.15% drops one drop each eye tid
humalog 50-50 28 unis sc qAM
lumigan 0.03% one drop left eye qhs
NPH 15U qAM
NPH 6U qPM
albuterol/atrovent q 4hrs prn
tylenol 650mg q 4hrs
imodium
cosopt eye drops one drop both eyes [**Hospital1 **]
lasix 20mg qday
colace 100 [**Hospital1 **]
zofran 4mg q 6hrs prn nausea
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-22**]
Puffs Inhalation Q4H (every 4 hours) as needed.
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: as
directed U Subcutaneous twice a day: NPH 15U qAM
NPH 6U qPM .
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): DC on [**2181-3-9**] . Tablet(s)
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Morphine 10 mg/5 mL Solution Sig: 1-2 mg PO Q6H (every 6
hours) as needed for pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
13. Colace 50 mg Capsule Sig: [**12-22**] Capsules PO twice a day.
14. Insulin Lispro 100 unit/mL Insulin Pen Sig: as directed U
Subcutaneous four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 3320**]
Discharge Diagnosis:
Primary: cholecystitis complicated by sepsis, acute renal
failure
.
Secondary: Adenocarcinoma of the head of the pancreas, aortic
stenosis, diabetes, glaucoma
Discharge Condition:
Stable vital signs, afebrile, tolerating POs
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital3 **] Medical
Center.
.
You were admitted with a severe infection of your gall bladder.
This is a complication of your pancreatic cancer and the stent
we placed to open up your bile duct. We placed a tube into your
gall bladder to drain the infection and treated you with
antibiotics. You will need to keep taking these antibiotics for
several days.
.
Please take your medications as ordered.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency room if you
experience fevers, chills, nausea and vomiting, diarrhea, chest
pain, shortness of breath, bleeding, loss of consciousness, or
other concerning symptoms.
Followup Instructions:
[**2181-3-14**] 01:00p [**Last Name (LF) **],[**First Name3 (LF) **] M.F. [**Telephone/Fax (1) 22**]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
.
Please see Dr. [**Last Name (STitle) **] in clinic in three weeks his number is
([**Telephone/Fax (1) 2363**]
Completed by:[**2181-3-2**]
ICD9 Codes: 5849, 0389, 4241, 2859 | [
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] | [
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train_44976 | completed | 53fa3d45-52fa-467b-ba0c-0f8b12ecb9ee | Medical Text: Admission Date: [**2154-5-7**] Discharge Date:[**2154-5-13**]
Date of Birth: [**2081-11-28**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male who was transferred here from [**Hospital3 3583**]. He was
admitted there on [**2154-5-5**] with a two week history of
paroxysmal nocturnal dyspnea, orthopnea, increasing
peripheral edema and exertional chest burning. He was
treated with Lasix. He ruled out for an MI. He was
transferred to the [**Hospital1 69**] on
[**2154-5-7**] in stable condition for catheterization.
PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia,
benign prostatic hypertrophy.
PAST SURGICAL HISTORY: Right ankle surgery.
ALLERGIES: None known.
MEDICATIONS: At home, HCTZ 25 mg q d, Zestril 5 mg q d,
Lipitor 10 mg q d, Hytrin 10 mg q d. Medications on
transfer, Zestril 10 mg q d, Lipitor 10 mg q d, Hytrin 10 mg
q d, Lasix 40 mg q d, Aspirin 325 mg q d, Lopressor 25 mg
[**Hospital1 **], Flonase one spray [**Hospital1 **], Nitro Paste one inch q 6 hours,
Heparin infusion which was discontinued.
FAMILY HISTORY: Lives with wife.
SOCIAL HISTORY: Smoker, quit 1?????? months ago.
HOSPITAL COURSE: The patient was admitted to the cardiac
medical service. He underwent a catheterization on [**2154-5-8**]
where they found severe three vessel disease with severe 95%
LM. The patient had an intra-aortic balloon pump placed and
was transferred to the CCU at which point a cardiac surgery
consult was obtained and the decision was made to operate on
[**2154-5-9**]. The patient underwent an urgent CABG times three
with LIMA to LAD, SVG to OM, SVG to PDA on [**2154-5-9**]. He was
transferred to the CSRU in stable condition. He was
extubated on postoperative day #1. Pump was also removed on
postoperative day #1. He was transferred to the regular
floor on postoperative day #2. He did complain of some low
back pain on postoperative day #2 and was given Toradol with
good pain relief. On postoperative day #3 his creatinine had
bumped from 1 to 1.4, his Toradol was discontinued, he was
hydrated and Flexeril was started for back pain. He got good
relief from this. On postoperative day #4 his creatinine
came back down to 1.2. His pacing wires were discontinued
and he is ready for discharge to a rehab facility when a bed
is available.
DISCHARGE MEDICATIONS: Aspirin 325 mg q d, Lopressor 25 mg
[**Hospital1 **], Lasix 20 mg q d times one week, KCL 20 mEq q d times one
week, Colace 100 mg [**Hospital1 **], Plavix 75 mg q d, Lipitor 10 mg q
h.s., Hytrin 10 mg q d, Flonase one spray [**Hospital1 **], Flexeril 10 mg
[**Hospital1 **], Percocet 1-2 tablets po q 4-6 hours prn.
FOLLOW-UP: With Dr. [**Last Name (STitle) **] in four weeks, with primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 15170**] in two weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2154-5-13**] 11:28
T: [**2154-5-13**] 11:32
JOB#: [**Job Number **]
RP [**2154-5-13**]
ICD9 Codes: 4280, 5180, 4019, 2720 | [
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] | [
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3
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train_46873 | completed | feb988a7-58ae-494d-9b4c-bbf3bdb15620 | Medical Text: Admission Date: [**2142-9-13**] Discharge Date: [**2142-9-28**]
Date of Birth: [**2082-7-14**] Sex: M
Service: [**Location (un) 259**] MEDICINE
HOSPITAL COURSE: Patient is a 60-year-old man with a history
of end-stage renal disease on hemodialysis, alcoholic
cirrhosis, who was brought to the [**Location (un) 620**] Emergency Room on
[**2142-9-7**] after his hemodialysis session when he was found to
be confused with a low-grade fever. His workup included
negative head CT and demonstration of no ascites on
ultrasound. He was found to have a left sided pleural
effusion on chest x-ray. This was tapped and found to be
with a white blood cell count of 2,000, red blood cell count
of 320,000, neutrophils 93, lymphocytes 2, monocytes 5,
glucose 1, LDH [**2074**]. This was unable to be fully drained.
One day prior to his discharge, the patient was febrile to
101.1. Was started on levofloxacin and metronidazole. He
was transferred to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 2742**] with
video assisted thoracostomy.
On presentation, the patient denied chest pain, shortness of
breath, nausea, vomiting, diarrhea, headache, fevers, chills,
or cough.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis.
2. Alcoholic cirrhosis.
3. Positive hepatitis A, B, and C.
4. Gout.
5. Hypertension.
6. History or MRSA line infection.
7. Delirium tremens.
ALLERGIES: Dilantin to which the patient gets a rash.
MEDICATIONS ON ADMISSION:
1. Ativan 0.5 mg prior to dialysis.
2. Folate.
3. Thiamine.
4. Protonix.
5. Nephrocaps.
6. Depakote p.o. b.i.d.
7. Lopressor 50 mg p.o. b.i.d.
8. Renagel 800 mg p.o. t.i.d.
9. Vicodin 1 mg p.o. q.4h. prn.
10. Levofloxacin 200 mg IV q48h.
11. Metronidazole 500 mg IV q.8h.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.5, blood
pressure 120/78, pulse 71, respirations 20, and sating 95% on
room air. In general, lying in bed comfortable. HEENT is
normocephalic, atraumatic. Right pupil smaller than left.
Slight ptosis of the left eye. Neck: No JVD. Chest:
Decreased breath sounds, dullness on the left, clear on the
right. Cardiovascular: Regular rate, normal S1, S2, with no
murmurs, rubs, or gallops. Abdomen is soft, mildly diffusely
tender, no fluid wave or rebound, positive bowel sounds.
Extremities: No clubbing, cyanosis, or edema. No palmar
erythema. Neurologic: No asterixis.
LABORATORY:
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Name8 (MD) 7583**]
MEDQUIST36
D: [**2142-9-28**] 13:45
T: [**2142-9-28**] 13:54
JOB#: [**Job Number 52058**]
ICD9 Codes: 9971 | [
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train_46415 | completed | 6a632b77-f7cb-476e-a406-41d0ecbce3c9 | Medical Text: Admission Date: [**2116-10-28**] Discharge Date:
Date of Birth: [**2116-10-28**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **]-[**Known lastname 10940**] was admitted to
the NICU from the DR. [**Last Name (STitle) 21206**] is a 32-year-old gravida 1, para
0, now 1 mother with a history of chronic hypertension as
well as PIH. The infant is a 28 [**5-7**] week gestation. Apgars
were 3, 6 and 8. The infant was intubated in the DR.
PRENATAL SCREENS were unremarkable. Birth weight was 880 gm,
head circumference 25 cm, length 33.5 cm.
Initial history and physical exam, the infant was brought to
the NICU, placed on an open warmer.
PHYSICAL EXAMINATION: Significant for a hematoma noted at
the base of the umbilical cord, otherwise non dysmorphic,
palate intact. Heart regular, no murmur appreciated. Lungs
clear/coarse. Abdomen soft, no hepatosplenomegaly. Femoral
pulses 2+ bilaterally. Moving all extremities. Anus patent.
Tone within normal limits for gestation.
ASSESSMENT: The infant is a 28 [**5-7**] week gestation male with
issues of:
1. Prematurity.
2. Surfactant deficiency.
3. Rule out sepsis.
4. Hyperbilirubinemia.
5. Leukopenia.
HOSPITAL COURSE:
1. Respiratory: The infant was intubated in the DR [**Last Name (STitle) **]
remained on mechanical ventilation initiated with PEEP of 5,
rate of 30. He remained intubated until
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 35940**], M.D. [**MD Number(1) 35941**]
Dictated By:[**Last Name (NamePattern4) 36237**]
MEDQUIST36
D: [**2116-11-20**] 15:55
T: [**2116-11-20**] 17:15
JOB#: [**Job Number 37257**]
ICD9 Codes: 769, 7742, V290, V053 | [
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] | [
"6b907695-7d26-4ebc-843d-9769e96a2f35"
] | [
"submitted"
] | [
3
] | [
"6b907695-7d26-4ebc-843d-9769e96a2f35"
] | [
"submitted"
] |
train_43279 | completed | 8c6f4116-9e7a-451c-ac5e-5edb90939b7f | Medical Text: Admission Date: [**2106-3-9**] Discharge Date: [**2106-3-15**]
Date of Birth: [**2040-12-6**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Suboccipital Craniotomy for mass resection
History of Present Illness:
65F with hx. of breast Ca. with bone mets, presented with 4
weeks of occipital headache. Associated symptoms are nausea and
vomiting, no change in vision, balance, smell. Had imaging (CT
+MRI) at OSH that showed cerebellar metastases with 8mm downward
herniation. 4th ventricle was near-totally obstructed, and
lateral ventricles were enlarged. She was given decadron 4mg IV
at [**Hospital3 4107**], and she received devadron 6mg IV in [**Hospital1 18**]
emergency [**Hospital1 **].
Past Medical History:
Breast cancer, s/p chemotherapy with Taxol.
Known mets to right femur/hip, s/p ORIF for fixation.
Hypertension
Social History:
Smokes
widowed, children.
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
98.2 62 137/68 20 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: bilaterally reactive to light
EOMs: intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-3**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Cerebellar testing:
No dysmetria with finger to nose bilaterally.
Unable to do hand flapping on left side. No problems with right
side.
Normal heel to shin bilaterally.
Exam upon discharge:
Slight left dysmetria, otherwise intact
Pertinent Results:
MRI:
OSH MRI: 3 cerebellar metasteses with 8mm downward herniation.
CT Head [**3-12**] Post op
No acute bleed.
Brief Hospital Course:
Pt was admitted to ICU and monitored closely and remained
stable. She was started on steroids. She transferred to floor
[**2105-3-10**]. She underwent CT torso for staging which appears to be
grossly stable when compared with history obtained from
oncologist. She was readied for the OR and underwent an
uncomplicated suboccipital craniotomy for tumor resection on
[**3-12**]. Post operatively she remained intubated and was
transferred to the ICU for further care including q1 neuro
checks and strict blood pressure control. On post op exam she
was awake and alert, following commands and moving all
extremities with full strength. She was extubated in the early
morning of [**3-13**]. Her diet was advanced and she was tolerating a
diet well. She was transferred to the floor in stable condition.
She was ambulatory in the halls without assistance and deemed
fit for discharge on [**3-15**]. She was given instructions for
follow-up and discharged
Medications on Admission:
HCTZ 25mg',Herceptin,Zometa
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever,pain.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO q3hours as needed
for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar Metastasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**8-8**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You will be contact[**Name (NI) **] by The Brain [**Hospital 341**] Clinic for meeting
regarding radiation with Dr [**First Name (STitle) 13014**]. He is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) 442**]. Your
appointment will msot likely be friday [**3-19**]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you have any questions
??????You will / will not need an MRI of the brain with/ or without
gadolinium contrast. If you are required to have a MRI, you may
also require a blood test to measure your BUN and Cr within 30
days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **]
please make sure to have these results with you, when you come
in for your appointment
Completed by:[**2106-3-15**]
ICD9 Codes: 4019, 3051 | [
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train_45357 | completed | 822859e5-f07c-40da-b9f2-39af22f589de | Medical Text: Admission Date: [**2159-9-3**] Discharge Date: [**2159-9-13**]
Date of Birth: [**2110-12-5**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Morphine
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
epigastric pain
Major Surgical or Invasive Procedure:
femoral central line placement
History of Present Illness:
Mr. [**Known lastname 33419**] is a 48 year-old Cuban gentleman with a history of
idiopathic dilated cardiomyopathy (EF 15-20%) s/p AICD [**2159-8-7**]
who presented to the Emergency Department with intermittant,
epigastric pain that is similar to his presentation at his last
admission on [**8-25**]. Also admits to bilious emesis. Denies any
f/chills. He reports pain worsened over the past 3 days with N/V
as well as abdominal distension and firmness. He reports some
increased dysuria intermittently for the past 2 days.
.
In the [**Name (NI) **], pt temp was 97.7, Hr 112, BP 110/69, 100%RA. He
received 1L NS, D5W + bicarb and mucomyst prior to receiving IV
contrast during his CT torso.
Past Medical History:
1. CHF: Idiopathic dilated cardiomyopathy. Echo [**6-2**] with LVEF
15-20%, mild-mod MR. [**Name14 (STitle) 33421**] [**4-30**] with global hypokinesis,
moderate dilation, no perfusion defects and normal EKG. Cath
[**8-2**] with no flow limiting coronary disease, elevated right and
left sided filling pressures consistent with biventricular
diastolic dysfunction (RVEDP = 16 mmHg, LVEDP = 31 mmHg),
moderate pulmonary arterial hypertension, markedly reduced
cardiac index, and markedly elevated SVR and PVR. Dry weight is
144lbs (65.5kg).
2. NSVT: Pt with several episodes during hospitalization in [**8-2**]
and underwent AICD placement.
3. h/o STDs: MSM. +gonorrhea [**2153**]. HBV core Ab+, sAb+. HIV neg
[**7-3**], HCV neg [**7-3**].
4. RUE DVT - on coumadin
5. ? Protein C and S deficient last admit
Social History:
The patient immigrated from [**Country 5976**] in [**2149**]. He currently lives
alone in [**Location (un) 686**]. He denies any use of alcohol, tobacco or
illicit drugs. He is a man who has sex with men (see above).
Family History:
CAD - Mother died of MI in her 50s. Brothers and sisters also
have "problems with their hearts." No known history of blood
clots.
Physical Exam:
Admission PE:
VS: T97.2 BP96/52 P116 R20 O2 95%RA
GEN: NAD, comfortable, Spanish-speaking gentleman, breathing
comfortably.
HEENT: PERRL. MMM. OP clear. No JVD.
HEART: RRR no m/r/g. Defibrillator site c/d/i without erythema
or swelling.
LUNGS: CTA B/L
ABD: soft, nondistended. Hyperactive BS. Diffuse TTP throughout
abd, but no rebound/guarding. Mild CVAT on R, none on L.
EXT: No edema bilat.
NEURO: AO x 3. No focal deficits
Pertinent Results:
Admission Labs:
.
[**2159-9-2**] 08:20PM BLOOD WBC-7.1 RBC-4.65 Hgb-13.1* Hct-38.5*
MCV-83 MCH-28.2 MCHC-34.0 RDW-15.7* Plt Ct-351
[**2159-9-2**] 08:20PM BLOOD Neuts-65.7 Lymphs-27.6 Monos-5.0 Eos-1.2
Baso-0.4
[**2159-9-2**] 08:20PM BLOOD Hypochr-1+ Microcy-1+
[**2159-9-2**] 08:20PM BLOOD PT-36.2* PTT-30.3 INR(PT)-4.0*
[**2159-9-2**] 08:20PM BLOOD Glucose-112* UreaN-20 Creat-1.3* Na-135
K-6.2* Cl-100 HCO3-21* AnGap-20
[**2159-9-2**] 08:20PM BLOOD ALT-54* AST-77* CK(CPK)-140 AlkPhos-157*
Amylase-30 TotBili-1.0
[**2159-9-2**] 08:20PM BLOOD Lipase-30
[**2159-9-2**] 08:20PM BLOOD CK-MB-2
[**2159-9-2**] 08:20PM BLOOD Calcium-8.8 Phos-4.6* Mg-2.2
.
Other labs:
[**2159-9-2**] troponin <0.01, CK 140
[**2159-9-5**] homocystein level 10
[**2159-9-5**] ACA IgM 8.0 and ACA IgG 5.2
[**2159-9-5**] prothrombin mutation not detected
[**2159-9-5**] Factor V leiden mutation not detected
.
CXR ([**2159-9-2**]):
1. Marked cardiomegaly, stable.
2. Interval improvement in the degree of congestive heart
failure with a tiny right pleural effusion.
3. Stable appearance of the transvenous pacemaker and leads.
.
CT Torso ([**2159-9-2**]):
1. Likely small subsegmental nonocclusive lingular pulmonary
embolus.
2. Heterogeneous right nephrogram, new from [**2159-7-31**], is
pyelonephritis versus renal infarcts.
3. A moderate right pleural effusion. (enlarged from [**2159-7-31**]), and small ascites (relatively unchanged).
.
Echo [**2159-9-3**]:
The left and right atrium are moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis. No masses or thrombi are seen in the
left ventricle. The right ventricular cavity is moderately
dilated with severe global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate to severe (3+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. Moderate [2+] tricuspid regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. Compared with the prior study (images
reviewed) of [**2159-6-12**],the findings are
similar.
.
Echo [**2159-9-4**]:
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed. No definite
thrombus identified (cannot definitively exclude). Spontaneous
echo contrast is noted in the left heart consistent with slow
flow. The right ventricular cavity is dilated. There is moderate
to severe global right ventricular free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
RLE U/S [**2159-9-6**]: no DVT
.
Discharge Labs:
.
[**2159-9-13**] 06:40AM BLOOD WBC-6.1 RBC-4.68 Hgb-12.7* Hct-38.4*
MCV-82 MCH-27.0 MCHC-33.0 RDW-16.4* Plt Ct-459*
[**2159-9-13**] 06:40AM BLOOD Plt Ct-459*
[**2159-9-13**] 06:40AM BLOOD PT-19.6* PTT-33.2 INR(PT)-1.9*
[**2159-9-13**] 06:40AM BLOOD Glucose-93 UreaN-23* Creat-1.1 Na-133
K-4.8 Cl-98 HCO3-24 AnGap-16
[**2159-9-13**] 06:40AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
Brief Hospital Course:
48 year-old M with nonischemic dilated CMP with EF<20%, multiple
VTE (DVT/PE) who presents with persistent epigastric pain
initially admitted to medicine, transfered to the MICU due to
hypotension on the same day, then CCU the next day for further
management of CHF (tailored therapy). His hospital course for
this admission is as follows:
.
1 CHF: Severe systolic CHF with EF <20% with moderate MR,
hypotension likely secondary to poor cardiac output. We
continued his digoxin at home dose. Central line was placed,
and he was started on dobutamine drip tailored therapy at
15/kg/min on [**2159-9-4**] which was gradually weaned to 12mcg/kg/min
on [**2159-9-6**], and weaned completely on [**2159-9-7**] and his central
line was pulled on the same day. We monitored him closely for
arrythmias on the tele while he was on the dobutamine drip.
Lasix, [**Last Name (un) **], and spironolactone was held initially given
increased Cr, while he was at the CCU, [**Last Name (un) **] (valsartan 40''),
lasix 40', aldactone 25' was restarted once his Cr function was
back to his baseline. He was held on most of his heart failure
meds given BP parameter setting (SBP<95), but we adjusted the
parameter to hold meds for SBP<85, and the decision was made not
to take him for right heart cath at the time since he was able
to tolerate his heart failure meds with changing parameters. He
was discharged home with valsartan 40mg PO qhs, lasix 80mg PO
qday, aldactone 25mg PO qday, digoxin 0.125mg PO qday.
.
2 Ischmia. No CP, no h/o CAD. initial troponin and CK negative.
.
3 Rhythm. pt had sinus tach, likely [**3-1**] to low cardiac output,
anticipate improvement.
.
4 Abdominal Pain. Leading diagnosis is congestion from CHF
causing pain from liver capsule expansion. Somewhat responsive
to PPI. He continued to complained abdominal pain while in the
hopsital, and seemed to improved with pain management. CT torso
initially was unrevealing. We followed his daily LFTs, which
continued to be mildly elevated but stable c/w with liver
congestion from his heart failure.
.
5 DVT/PE. Unclear etiology. RUE VTE developed at home, not in
setting of line placement. Patient now developed a small PE
while supratherapeutic on coumadin. Concerning for
hypercoagulable state. Hem/Onc was consulted, but was difficult
to send hypercoagulable stuides given patient already
anticoagulated; we sent antiphospholipid Ab which was WNL, pt
didn't carry the more common factor [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5244**] mutation and
Prothrombin mutations, homocysteine levels was WNL; His
initially INR was supratherapeutic 4.0->3.5, coumadin was held
initially; coumadin was restarted at 3mg PO qhs when INR came
down to 2.5. Given Echo showed questionable LV thrombus and
given ? hx of hypercoagulable state, he was also started on
Lovenox 60mg SC q12h when INR became undertherapeutic (INR<2.0)
while on Coumadin. He also finished a 7 day course for Kefelx
for superifical thrombophlebitis.
.
6 R renal infarct. Noted on CT torso, new finding which was
concerning for thromboembolic disease, possibly LV thrombus give
dilated CMP predisposing to intracardiac stasis. Echo aslo
suggestive of poor flow. No clots seen on echo however. No
evidence of endocarditis given no fevers, bl cx negative to date
from ED. We continued anticoagulation with coumadin and
lovenox (when INR<2.0), and monitored renal function closely
where Cr trending down to baseline.
.
7 Cr elevation. Baseline 1.0, initially slightly elevated
secondary to poor cardiac output +/- renal infarct. anticipate
improvement with improved cardiac output on pressors. We held
lasix and [**Last Name (un) **] initially given slightly elevated BUN/Cr; once Cr
back to his baseline, [**Last Name (un) **] and lasix was restarted.
.
8 Pain syndrome. Multifactorial, mainly around his ICD site (no
signs of infection and remained afebrile thorughout the hospital
course) and abdomen (most likely related to congestive
hepatopathy). Chronic pain service was consulted, which
recommended oxycodone 5-15mg PO q4h prn, tradmadol 50mg PO q4-6h
prn, and gabapentin 600mg PO tid, and lidocaine 5% patch 12
hours on and 12 hours off. Patient's pain slightly improved on
this regimen.
.
9 Congestive hepatopathy. LFTs mildly elevated initally, we
followed closely his daily LFTs, which remained slightly
elevated but stable.
.
10 FEN: cardiac diet, fluid restriction 1500ml/day, lyte
repletion prn
.
11 PPx: INR elevated initially, once therapeutic, started
coumadin (and lovenox and INR<2.0), bowel reg prn, po diet, PPI
.
12 Full Code
Medications on Admission:
Medications at Home:
Pantoprazole 40 mg Q24H
Digoxin 125 mcg PO DAILY
Spironolactone 25 mg PO DAILY
Valsartan 40 mg PO BID
Carvedilol 12.5 mg PO BID
Tramadol 50 mg PO Q4-6H as needed
Furosemide 20 mg PO qOD
Warfarin 2mg qhs
Oxycodone 10mg q4, prn
Keflex 500 [**Hospital1 **] x2 more days
.
Meds Upon Transfer to CCU:
- Digoxin 0.125 mg PO DAILY
- OxycodONE (Immediate Release) 10 mg PO Q4H
- OxycodONE (Immediate Release) 5 mg PO Q6H:PRN
- Pantoprazole 40 mg PO Q24H
- traMADOL 50 mg PO Q4-6H:PRN
- Dolasetron Mesylate 12.5 mg IV Q8H:PRN
- Cephalexin 500 mg PO Q6H Duration: 2 Days
Discharge Medications:
1. 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*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP<85.
Disp:*15 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*45 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for SBP<85.
Disp:*15 Tablet(s)* Refills:*0*
7. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice
a day for 3 days.
Disp:*6 syringes* Refills:*0*
8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): hold for BP<85.
Disp:*15 Tablet(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times
a day: hold for oversedation.
Disp:*90 Capsule(s)* Refills:*0*
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily):
hold for SBP<85.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*0*
13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical once a day: apply for
12 hours, and remove for 12 hours.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
15. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO every six (6)
hours as needed: hold for oversedation and RR<12.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Idiopathic dilated cardiomyopathy
chronic pain
.
Secondary diagnosis:
NSVT s/p AICD placement [**8-2**].
h/o STDs: MSM. +gonorrhea [**2153**]. HBV core Ab+, sAb+. HIV neg
[**7-3**], HCV neg [**7-3**].
RUE DVT/small subsegmental PE - on coumadin as outpatient
Chronic pain - [**3-1**] AICD placement, DVT, superficial
thrombophlebitis, abdominal pain
Discharge Condition:
Patient is in stable condition, afebrile, no chest pain,
shortness
of breath, Blood pressure stable, ambulating, O2 sat in the
upper 90%.
Discharge Instructions:
If you experience any chest pain, SOB, heart palpitations,
fever, abdominal pain different than your baseline or any other
serious medical conditions, please go to the emergency room
immediately.
.
You heart is dilated and not pumping well. Please restrict
fluid intake to less than 1500ml per day. Please weigh yourself
everyday, if your weight increased by more than 5-10lbs, please
contact your PCP or your cardiologist immediately. Please make
sure you take all your heart failure medications which may help
your abodominal pain, including:
digoxin 0.125mg po qday
lasix 80mg PO qday
toprol XL 50mg PO qday
aldactone 25mg PO qday
valsatan 40mg PO every night
.
You are on coumadin (indefinitely) and lovenox( for three days
only), blood thinners. It is very important that you take
coumadin everynight, please have your INR checked regularly by
your PCP to keep it within the therapeutic range (goal INR [**3-2**])
to prevent clots development in your heart which can cause
stroke and other serious problems. Please make sure you get
lovenox shot 60mg SC bid for three days in addition to take
coumadin 3mg PO every night indefinitely to allow INR be in the
therapeutic range.
.
You have chronic pains, and we consulted chronic pain management
team, they recommended you taking oxycodone 5-15mg PO every [**5-3**]
hours as needed for pain control, tramodal 50mg PO every [**5-3**]
hours as needed for pain control, lidocaine 5% patch 12 hours on
and 12 hours off, and gabapentin 600mg by mouth three times a
day for pain control. If you experience pain different than
your baseline, please seek medical attention immediately.
.
Please take your medication as prescribed.
.
Please follow up with your appointments see below.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33426**] [**Name (STitle) **] ([**Telephone/Fax (1) 250**])
on [**2159-9-24**] 9:50am and follow up with Dr. [**First Name (STitle) 437**] on [**2159-9-17**] at
10:30am for INR check and appointments
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2159-9-24**] 9:50
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2159-9-17**] 10:30am
Completed by:[**2159-9-14**]
ICD9 Codes: 5849, 4254, 5859, 4280, 2859 | [
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train_44540 | completed | 8f4be56c-3bd0-47ff-b582-59e783c3fa13 | Medical Text: Admission Date: [**2101-8-19**] Discharge Date: [**2101-8-22**]
Date of Birth: [**2031-6-19**] Sex: M
Service: CCU
HOSPITAL COURSE: The patient was admitted on [**2101-8-19**], after
ventricular fibrillation cardiac arrest, intubated and
shocked in the field, transferred from outside hospital for
catheterization at [**Hospital1 69**].
Cardiac catheterization showed normal coronary arteries with
n coronary artery disease.
On examination, the patient was intubated and sedated. The
pupils were fixed at 4.0 millimeters and nonreactive. The
patient was with myoclonic jerks.
The laboratories at that time were significant for potassium
1.9. Despite multiple attempts to replete the potassium, it
only climbed slowly. He had a CT scan that showed blurring
of the [**Doctor Last Name 352**] white junction consistent with anoxic injury.
Neurology was consulted and family decided to make the
patient comfort measures only. He was extubated and his
blood pressure and heart rate continued to decline until he
expired [**2101-8-22**], at 7:07 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 2918**]
MEDQUIST36
D: [**2101-8-22**] 11:29
T: [**2101-8-29**] 18:14
JOB#: [**Job Number 102557**]
ICD9 Codes: 4275, 5070, 5849, 5990, 2768 | [
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train_44593 | completed | 27cd0692-160c-4deb-a9fb-0d57c7b8d6fc | Medical Text: Admission Date: [**2173-8-7**] Discharge Date: [**2173-8-12**]
Date of Birth: [**2096-12-2**] Sex: F
Service: NEUROLOGY
Allergies:
Ondansetron
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
PCA stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The pt is a 76-year-old woman R handed woman with end stage
PD, Sz disorder and dementia who is transferred from OSH for
further management of her "PCA stroke and other medical
problems."
According to transfer records (incomplete at best), it appears
that on [**2173-8-2**] she had a ? Sz at her NH. She was brought to the
[**Hospital 4199**] Hospital ED, where VS were 93/54, O2 sat of 85% on
unknown amount of O2. Due to "difficulty" maintaing O2 sats, she
was intubated in the ED. Of note, was also found to have small
amount of coffee ground emesis. Course was complicated by R PNX
after a subclavian line placement. At this point, she was
admitted to [**Hospital1 8**] ICU for "? shock". Her course was
complicated by R PNX, VAP, severe hypertension, then
hypotension,
electrographic evidence of Sz, dropping HCT and acute stroke on
[**8-7**]. She was transfered to [**Hospital1 18**] for further managment and
evaluation of the stroke and medical problems.
On admission to [**Hospital 8**] hospital ICU, it appears that patient
was noted to have elevated WBC to 24K and CXR w/ ? LLL
infiltrate. For this she was started on Vancomycin/Cefepime for
/
aspiration PNA. Subsequent ET suction tube SpCx grew out MRSA.
As
respiratory status improved, intubation was planned, however
patient had persistently "altered mental status." EEG was
performed that showed "moderate number of bursts and runs of
epileptiform activity in L parietal region and becoming more
generalized.." Given this, her Keppra dose was increased from
250mg [**Hospital1 **] to 750mg [**Hospital1 **]. She remained w/o improvedment, and on
[**8-7**]
she was given 1g of ativan IV, and loaded w/ 500mg of Dilantin.
Given that no improvement was noted, she underwent a NCHCT on
[**8-7**]. This showed a new (compared to [**8-2**] HCT) L hypodensity in L
PCA territory w/ L cerebellar hemishpere hypodense focus in the
L
cerebellum. No mass effect or hemorrhage was noted. Given this
she was started on ASA 81mg and transferred to [**Hospital1 18**] for further
management. Of note, she had episodes of hypertension on [**8-4**] abd
[**8-5**] to max of 240s/140s. This was felt to be due to pain from
chest tube, treated w/ labetalol, morphine and captopril. There
was report (verbal) that patient was felt to be in HF and thus
received lasix IV, with signficant diuresis and episode of
hypotension to 90s systolic. She was resuscitaed w/ IVF w/ SBPs
returning to 120s. There was also report of elevated Troponin to
0.83, however, no documentation was provided. Her ECGs were
sinus
tachycardia with PACs. On [**8-7**] she was also noted to have green,
loose stools, Cdiff neg x1.
She had been on Zonisomide for ? Tremors, but has been tx for Sz
disorder with this as well. The dose had been increased by Dr.
[**First Name (STitle) **] as a neurology consultant at [**Hospital6 12736**] for
a
series of "possible convulsions." - desribed as becoming
unresponsive, shaking and vomiting in front of her husband. At
this time [**7-21**] she was also started on Keppra 250mg [**Hospital1 **]. Per
that
note, prior MRIs were remarkable for b/l GP atrophy,
mineralizatonof BG on b/l and cerebellar midline atrophy.
During her last visit with Dr. [**First Name (STitle) 951**], [**3-11**], she was unable to do
so very much herself or provide much history. She needed help in
order to get out of the car. She has had frequent falls and
episodes of LOC. She sleeps much of the day. She requires
assisst
w/ ADLs.
Exam at that time was notable for being alert, mostly with eyes
closed but following simplevoice commands. No spontaneous
speech.
Disoriented to date/place, but knew her husbands name, poor
recall and naming. She also had facial hypomimia, monotone and
hypophonic speech, mild UE rigidity and nl LE tone. Flx
contractures of
the left hand, RAMs impaired and slow heel taps. She could arise
easily and quickly from the chair without assistance, gait was
slow.
She was admitted to [**Hospital 4199**] Hospital [**Date range (1) 46278**]/09 with ? seizure.
Head CT was "negative," her zonegran was increased to 50 mg q
AM,
100 mg at night.
ROS could not be obtained.
Past Medical History:
*Multiple falls - First episode in Summer [**2168**] - found
unresponsive on kitchen floor, woke up in minutes - single
episode not worked up extensively; second episode [**2170-5-13**] -
found down, extensive w/u at [**Hospital1 2025**] d/c [**2170-5-25**] with no known
etiology and plan for Holter; [**5-31**] - found down with LOC ended
up going to [**Hospital1 2025**] MICU for unclear reasons: (-) EEG, (-) [**Name (NI) 1608**]
*Parkinson's disease x 18 years- followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] as
outpt.
*h/o asthma/?COPD- dx at [**Hospital1 2025**] with occasional albuterol
*Seizure disorder, hx of head trauma at age 3, Sz since 5-6
years.
Social History:
Lives at home with her husband until increased
episodes of Sz. Currently lives in [**Location **]. Spends most of time
sleeping, dependent on ADLs.
Family History:
nc
Physical Exam:
Vitals: T: 98.7F P:72 R: 16 BP:106/78 SaO2:95% on 4LNC.
General: eyes closed, moaning, not responding to voice.
HEENT: NC/AT, dMM, no lesions noted in oropharynx, missing
multiple teeth. NGT in place w/ bilious material.
Neck: Supple, no carotid bruits, R subclavian line.
Pulmonary: Crackles B/l up to apices
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: cool, dry, no edema. 2+ radial, 1+ DP pulses
bilaterally.
Skin: no rashes, L forarm stage II ulcers, dressing on.
Neurologic:
-Mental Status:
Eyes closed, moning spontaneously, does not open eyes to command
or sternal rub, but grimaces to sternal rub with moans.
PEERL 5->3mm b/l, oculocephalic reflex intact, corneals present,
eyes were forced open by examiner w/ patient resistance noted.
VF
- blinks to threat b/l. Mouth was opened by examiner with
resistance from patient. Palate appeared to be midline. She did
not localize w/ UEs to noxious at orbital location.
Patient would move L wrist spontaneously, which at rest is
flexed
and fisted. There is cogwheeling on L > R, tone increased b/l in
UEs. She withdrew flexor to b/l UEs and localized to pain in the
clavicle b/l. Increased tone in [**Last Name (LF) **], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 46279**] flx to pain,
there was no localization.
DTRs were 2+ at biceps and triceps and 3+ at patella R, 2+ on L.
No reflex at achilles. Clonus in L foot for 4 beats, none at R
LE. Plantar flx on L and extensor on R.
Pertinent Results:
[**2173-8-8**] 03:06AM BLOOD WBC-12.8* RBC-3.21* Hgb-9.4* Hct-29.9*
MCV-93 MCH-29.2 MCHC-31.4 RDW-13.1 Plt Ct-284
[**2173-8-7**] 09:55PM BLOOD Neuts-81.2* Lymphs-10.0* Monos-5.3
Eos-3.4 Baso-0.1
[**2173-8-7**] 09:55PM BLOOD PT-12.9 PTT-25.8 INR(PT)-1.1
[**2173-8-8**] 03:06AM BLOOD Glucose-103 UreaN-7 Creat-0.6 Na-141
K-3.6 Cl-108 HCO3-25 AnGap-12
[**2173-8-7**] 09:55PM BLOOD ALT-1 AST-18 LD(LDH)-348* CK(CPK)-41
AlkPhos-88 TotBili-0.6
[**2173-8-8**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2173-8-8**] 03:06AM BLOOD Calcium-8.8 Phos-1.9* Mg-1.9
[**2173-8-7**] 09:55PM BLOOD %HbA1c-6.2*
[**2173-8-7**] 09:55PM BLOOD Triglyc-165* HDL-35 CHOL/HD-5.5
LDLcalc-126
[**2173-8-7**] 09:55PM BLOOD TSH-3.0
[**2173-8-8**] 09:29AM BLOOD Vanco-22.3*
[**2173-8-7**] 09:55PM BLOOD Phenyto-5.4*
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2173-8-8**]
11:26 AM
HISTORY: 76-year-old woman with Parkinson's, with large stroke.
Had recent
pneumothorax after placement of central venous catheter by
report.
Questionable free air under the right diaphragmatic contour.
Concern for
bowel perforation.
COMPARISON: None.
TECHNIQUE: Helical MDCT images were acquired from the bases of
the lungs to
the pubic symphysis after administration of oral and IV
contrast. Multiplanar
reformatted images were obtained.
FINDINGS:
CT ABDOMEN WITH CONTRAST: Dependent atelectasis is seen at the
bases of the
lungs and a small right-sided pleural effusion is noted. Along
the lateral
right chest wall, there is subcutaneous emphysema tracking to
the axillary
region. Linear atelectasis is present in the bilateral upper
lobes.
Nodular density at right lung base is likely rounded
atelectasis. The lungs
are otherwise clear without pneumothorax. The visualized heart
is normal. In
the abdomen, there is one subcentimeter hypodense lesion in the
liver, the
right hepatic lobe, incompletely evaluated. The gallbladder is
nondistended
without CT evidence of stone. The pancreas, spleen, adrenal
glands are normal.
There are bilateral subcentimeter hypodensities in the renal
parenchyma, too
small to be evaluated but likely to be cysts, and left
parapelvic cysts. There
is bilateral prompt excretion of contrast into the collecting
system and
proximal ureter although patchy heterogeneity of the nephrograms
particularly
on the left are of uncertain signficance. The stomach, duodenum
and loops of
small bowel are normal. There is no lymphadenopathy. There is no
free air or
free fluid in the intra- abdominal cavity.
CT PELVIS WITH CONTRAST: There is an indwelling Foley catheter
within a
normally distended bladder. The uterus is normal in size for a
postmenopausal
female. The colon and loops of small bowel are within normal
limits. There
is no lymphadenopathy. There is no free air or fluid in the
pelvic cavity.
BONE WINDOWS: No acute fracture or dislocation. No suspicious
lytic lesions
or sclerotic lesions. There is a single level degenerative
disease at L3 and
4 with anterior osteophytosis.
Of note, the NG tube is seen with tip in the stomach.
IMPRESSION:
1. No evidence of pneumoperitoneum or bowel perforation.
Subcutaneous
emphysema in the right lateral chest wall and axillary region.
This may relate
to a reported recent right pneumothorax seen at an outside
hospital.
2. Mild heterogeneity of nephrograms of uncertain significance
although
correlation with renal function is advised.
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2173-8-8**] 12:07 AM
CTA OF THE HEAD AND NECK WITH CONTRAST, [**2173-8-8**]
HISTORY: 76-year-old woman with Parkinson's disease with "large
posterior
circulation stroke, at OSH"; assess for bleed, thrombi, or
dissection.
TECHNIQUE: Routine [**Hospital1 18**] study including contiguous 5-mm axial
MDCT sections
from the skull base to the vertex prior to contrast
administration, with
helical 1.25-mm axial sections from the level of the aortic arch
through the
vertex during dynamic intravenous administration of 80 mL
Optiray-320.
Sagittal, coronal, and axial 10-mm sections, as well as
rotational 3D
volume-rendered reconstructions of both the cervical and
intracranial vessels,
and rotational curved multiplanar reformations of the cervical
vessels were
reviewed on the workstation.
FINDINGS: The study is compared with the NECT of the head
([**Hospital 8**]
Hospital) obtained some nine hours earlier.
There has been no overall short-interval change in the
appearance of the
large, virtually complete left posterior cerebral arterial
territorial
infarction with extensive cytotoxic edema throughout this region
and
involvement of the lateral portion of the ipsilateral thalamus,
likely
splenium of corpus callosum and posteromedial temporal lobe.
There are
scattered curvilinear internal relatively hyperattenuating foci,
also not
significantly changed, which may represent petechial hemorrhage
or, less
likely, "islands" of spared brain. There is a vaguely triangular
low-attenuation focus within the right hemipons, not clearly
present earlier
and difficult to confirm on the post-contrast images, which may
be artifactual
or represent additional relatively acute infarction. There is no
evidence of
involvement of additional vascular territories.
While there is atherosclerotic mural calcification involving the
superior
aspect of the aortic arch, as well as the left subclavian
arteries, there is
little atherosclerotic disease involving the common and internal
carotid
arteries throughout their course, to the level of the carotid
termini. These
vessels demonstrate normal caliber, with the left ICA measuring
6 mm at its
proximal portion, just distal to the bifurcation and 5 mm at the
skull base,
and the right internal carotid artery measuring 7 mm proximally,
just distal
to the bifurcation and 5 mm, more distally, at the level of the
skull base,
with, therefore, no flow-limiting stenosis. The vertebral
arteries are
roughly co-dominant and demonstrate normal caliber, contour, and
contrast
enhancement throughout their course, with no flow-limiting
stenosis or
evidence of dissection. There is a normal appearance to the
vertebrobasilar
confluence, and normal contrast opacification and caliber of the
principal
vessels of the circle of [**Location (un) 431**], without significant mural
irregularity or
flow-limiting stenosis. Specifically, there is a normal
appearance to the
left posterior cerebral artery from its basilar artery origin
throughout its
more distal portion, which can be followed to the periphery of
the infarcted
vascular territory.
IMPRESSION:
1. No significant further interval extension of the large,
virtually complete
left PCA arterial territorial infarction since the [**Hospital 8**]
Hospital study
obtained some nine hours earlier. This infarct involves the
ipsilateral
thalamus, medial temporal lobe and, likely, [**Last Name (un) 46280**] portions of
the splenium
of the corpus callosum.
2. Internal round and linear relatively hyperattenuating foci,
in this
context, suspicious for "petechial" hemorrhagic conversion.
3. Vaguely triangular low-attenuation focus within the right
hemipons, not
clearly present earlier and difficult to confirm on the
post-contrast images,
which may be artifactual or represent additional relatively
acute infarction.
4. Unremarkable appearance to the circle of [**Location (un) 431**] without
significant mural
irregularity or flow-limiting stenosis; specifically, the left
PCA is normal
in caliber and opacification throughout its course through the
infarcted
territory, and may be recanalized.
5. Normal appearance to the common and internal carotid and
vertebral
arteries, bilaterally, with no significant mural irregularity or
flow-limiting
stenosis.
Brief Hospital Course:
Ms. [**Known lastname 46281**] is a 76 year-old woman w/ hx of advanced PD,
dementia, and Sz disorder, with worsening Sz frequency, recently
admitted to [**Hospital 8**] hospital s/p seizure and intubation for
"hypoxic respiratory failure", VAP, hypertensive emergency,
hypotension, who now presents with a new stroke in posterior
circulation distribution, most likely embolic in nature.
The patient was initially admitted to the Neuro ICU for her
large posterior circulation infarct. Blood pressures were
allowed to autoregulate, and she was evaluated for remediable
stroke risk factors. Given her known seizure disorder, she was
continued on Keppra and Zonegran. She had an elevated white
count, which was attributed to pneumonia, for which she was
continued on Vancomycin, with repeat cultures.
After extensive discussion with the family, based on her
multiple severe medical problems, and deteriorating condition,
the decision was made to make the patient CMO. She was placed
initially on a morphine drip, later transitioned to Dilaudid,
with Ativan as needed. She remained comfortable, with her
family present. She passed away early in the morning on [**8-12**].
Medications on Admission:
- ASA 81mg daily
- Lipitor 80mg daily
- Zonegran 100 mg [**Hospital1 **]
- Keppra 750mg [**Hospital1 **]
- Sinemet 15/100 [**12-4**] tab Q8H, then 1 tablet Q11,14,17,20
- Zosyn IV 3.375 Q6H
- Vanco IV 1g Q12
- Protonix 40mg IV daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Large posterior circulation stroke
Seizure disorder
Parkinson's disease
Discharge Condition:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 5849, 4019, 2859 | [
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"624788f6-482b-4389-a2d5-db8fd9925c88"
] | [
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] | [
3
] | [
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] | [
"submitted"
] |
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