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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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train_43434 | completed | 6f7f6313-2f4e-4b22-8562-b55e69b7edf4 | Medical Text: Admission Date: [**2150-2-7**] Discharge Date: [**2150-3-18**]
Date of Birth: [**2108-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
variceal bleed
Major Surgical or Invasive Procedure:
[**Last Name (un) **] probe insertion, twice
TIPS placement, with revision
Intubation
History of Present Illness:
HPI: 41 yo with etoh cirrhosis here after 3 days of progressive
nausea and womiting bright red blood. In total about 500cc and
finally presented to [**Hospital3 3583**] with the bleeding,
reportedly found to have a Hct of 19 and hypotensive, was given
7 units of PRBC, FFP and Vitamin K. There he had an EGD which
showed large esophageal varices with recent signs of bleeding
and gastric varices of which the esophageal verix was sclerosed.
Started on octreotide and prononix drip and Hct prior to
transfer was 29.
.
On arrival here feels better, no longer with nausea, no recent
vomiting, or any pain. Feels better after transfusion. Last
vomitied 3 am this am. Last BM an hour ago still dark, marroon
colored stool. He denies any hx of GI bleed in past, last drink
[**2150-1-23**] when detoxed from etoh, had previously drank 2pints of
Vodka and none currently.
.
ROS: very hungry and thirsty, over last yr has had about 40lb
unintentional weight loss, noted scleral icterus over last 1.5
yrs, and SOB prior to ED visit otherwise no other complaints.
Past Medical History:
etoh cirrhosis, per pt hepatitis w/u as outpt was negative
etoh abuse-- recent detox [**2150-1-23**]
DM-- on metformin/glucotrol
HTN-- on lisinopril
depression-- on GERD
Social History:
married, works as a car salesman, no hx of drug/IV drug abuse,
secually active only with wife, previous 2pints/vodka/day, 1ppd
x12yrs
Family History:
+hx of DM and heart disease, no liver disease
Physical Exam:
PE:
VS: 139/69 P 79 Rr24 Sat 97%RA
GEN aao, nad
HEENt +Scleral icterus, dry MM
CHEST CTAB no wheezes, rales
CV RRR no murmurs
ABD soft NT/ND, +BS, no ascites, +guiaic positive maroon colored
stool
EXT no edema or asterixis
Pertinent Results:
[**2150-2-7**] 09:30PM URINE MUCOUS-RARE
[**2150-2-7**] 09:30PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2150-2-7**] 09:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2150-2-7**] 09:30PM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2150-2-7**] 09:30PM PLT COUNT-110*
[**2150-2-7**] 09:30PM PT-15.0* PTT-28.4 INR(PT)-1.5
[**2150-2-7**] 09:30PM WBC-10.4 RBC-2.95* HGB-9.8* HCT-27.4* MCV-93
MCH-33.2* MCHC-35.7* RDW-18.6*
[**2150-2-7**] 09:30PM HCV Ab-NEGATIVE
[**2150-2-7**] 09:30PM IgG-799
[**2150-2-7**] 09:30PM AFP-3.4
[**2150-2-7**] 09:30PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2150-2-7**] 09:30PM ALBUMIN-2.6* CALCIUM-7.2* PHOSPHATE-2.9
MAGNESIUM-1.2*
[**2150-2-7**] 09:30PM LIPASE-27
[**2150-2-7**] 09:30PM ALT(SGPT)-41* AST(SGOT)-80* LD(LDH)-198 ALK
PHOS-77 AMYLASE-30 TOT BILI-3.2*
[**2150-2-7**] 09:30PM GLUCOSE-166* UREA N-21* CREAT-0.7 SODIUM-145
POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
.
Abdominal US [**2150-2-9**]
1. Reversal of normal portal flow. No evidence of portal
thrombus.
2. Echogenic, small shrunken liver, with ascites. Focal liver
lesions in this echogenic liver cannot be excluded on the basis
of this study.
.
TIPS placement [**2150-2-9**]
1. Transjugular intrahepatic portal systemic shunt placement.
However,little flow through the TIPS after the procedure. Most
flow still through the significantly dilated varices and
spontaneous splenorenal renal shunt. The sheath was left in
situ for further evaluation at the next day.
2. Unsuccessful attempt to sclerose varices arising from the
portal and splenic veins with absolute alcohol.
3. Successful ultrasonographic guidance paracentesis with
withdrawal of 3000cc of ascites.
.
TIPS revision [**2150-2-10**]
1. Successful reversion of transjugular intrahepatic portal
systemic shunt with reduction of a pressure gradient between the
portal vein and the right atrium.
2. Successful embolization of coronary vein varix.
.
Abd US [**2150-2-11**]
Patent TIP shunt with velocities ranging from 30-130 cm/sec.
There is a focal area with lack of wall-to-wall flow in the mid
TIPS, which should be reevaluated by repeat study tomorrow. If
this is persistent, possibility of a clot within the TIP shunt
must be considered and hence short- term reevaluation is
necessary. A large coarse echogenic liver without focal lesions.
Ascites. Gallbladder sludge.
.
Liver US [**2150-2-13**]
1. Trace amount of perihepatic ascites, insufficient in size to
safely mark a spot for paracentesis.
2. Large coarse echogenic liver, without focal lesions
.
Chest XR [**2150-2-16**]:
There is an endotracheal tube, whose distal tip is at the level
of the clavicles. There is a right-sided central venous
catheter with the distal tip in the SVC. There has been
interval placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube with the distal tip
projecting over the pylorus. The inflated balloon of the tube
is in the fundus of the stomach. There is a stent seen within
the right upper quadrant consistent with the TIPS. There is
complete opacification of the left lung with volume loss in this
region. This may be secondary to large pleural effusion versus
consolidation. The lateral half of the right chest has been
excluded from the study. There
is vascular congestion in the visualized portions of the right
lung.TIPS revision [**2150-2-16**]
Embolization of varices arising from the splenic vein using a
total of 38 coils (the varices rise from the coronary vein and
two branches of the splenic vein). Balloon dilation of the TIPS
with a 10-mm angioplasty balloon. Significantly increased flow
through the TIPS and decreased variceal flow.
.
Abd US [**2150-2-18**]
Patent TIPS with velocities ranging from 52-206 cm per second.
Note is made of interval increase in velocity within the distal
aspect of the TIPS. Continued short term surveillance may be
appropriate.
.
Chest XR [**2-19**]/-6
1. Interval development of right upper lobe collapse.
2. Stable-appearing left lower lobe atelectasis and collapse.
3. [**Last Name (un) **] tube seen within the stomach. The balloon is not
identified.
.
CT abdomen: [**2149-2-26**]
1. No evidence of intra-abdominal bowel pathology.
2. Decompensated liver failure with portal hypertension and
ascites. Patient is status post TIPS placement and variceal
coiling.
3. Splenorenal shunt.
4. Air in bladder reflects an indwelling catheter.
.
ECHO [**2150-3-3**]
Trace aortic regurgitation with normal valve morphology.
Preserved global and regional biventricular systolic function.
.
Chest XR [**2150-3-7**]
There is a left-sided central venous catheter with distal tip in
the proximal SVC. This is unchanged in position. There is a
feeding tube identified with its tip below the gastroesophageal
junction. The cardiac silhouette is enlarged but unchanged.
There are low lung volumes secondary to poor inspiratory effort.
There is again seen bilateral pleural effusions and a left
retrocardiac opacity unchanged. Pulmonary vascular markings are
prominent consistent with mild-to-moderate edema which is also
unchanged.
.
Left upper extermity US [**2150-3-12**]
There is no evidence of DVT.
.
Chest XR [**2150-3-12**]
Improvement in appearance of the right lung likely related to
partial resolution of pulmonary edema. Cardiomegaly is still
present and there is still evidence of CHF. Unchanged
retrocardiac opacity consistent with atelectasis.
Brief Hospital Course:
41 yo man with DM, HTN, Alcoholic cirrhosis with new variceal
bleed admitted on [**2-7**].
.
#. GI bleed: In the MICU the pt continued to have hematemesis
despite octreotide and protonix iv but an initial EGD did not
show any active bleed therefore further sclerosing was deferred.
Due to extend of the both esophageal and gastric varices an
urgent transjugular intrahepatic portal systemic shunt was
placed on the [**2150-2-9**]. Which intially did not show sufficient
flow but was then successfully revised on the [**2150-3-13**] with
reduction of a pressure gradient between the portal vein and the
right atrium. Also, successful embolization of coronary vein
varix. Then reocclussion and revision on the [**2150-2-16**]. The pt
continued to have hematemesis and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] tube was inserted
on the [**2-12**] and subsequently removed on the [**2-13**] b/o
stabilization. Octreotide was discontinued. A repeat EGD on the
[**2-16**] showed varices at the middle third of the esophagus and
lower third of the esophagus as well as varices at the fundus.
Otherwise normal egd to stomach antrum. It was determined that
there was still high risk for rebleeding. Because of rebleeding
that day another EGD was done and 2 bands were placed without
cessation of bleeding. Octreotide was restarted. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**]
probe was reinserted and a revision of the TIPS was performed on
the same day. A coiling procedure to embolize bleeding vessels
was performed. THe pt stabilized and the [**Last Name (un) 10045**] was removed
on the [**2150-2-20**]. Octreotide was continued. The pt had a mild
oozing of blood on the [**2150-2-21**] but was stable since then.
Octerotide was discontinued on the [**2150-2-25**]. The pt did not have
any evidence of bleeding since the [**2150-2-22**]. The pt received a
total of 40 U of Fresh frozen plasma, 24 U of PRBC in addition
to the 7U received at the OSH and 9U of platelets throughout his
stay in the ICU. Nadolol was started on the [**2150-3-7**]. The pt
continued to be trace guaiac positive, but did not have any more
signs of gross bleeding. The hematocrit continued to trend down
slowly, which was attributed rather to hemolysis in the context
of liver disease than to low grade GI bleed. The pt has a very
high risk of rebleeding given the extend of his disease. The
pt??????s family was made aware of severity of pt's condition. The pt
has not required any blood transfusions since [**2150-3-8**] and has
maintained a stable hematocrit since then.
.
# BP/Hypotension: The patient is hypertensive at baseline. He
was found to have episodes of hypotension requiring Levophed in
the context of severe blood loss and later sepsis. Adrenal
insufficiency along with hepatic failure/anasarca/
hypoalbuminism were thought to be contributing in the etiology.
There was no evidence of a cardiac event. Patient cortisol level
on [**2-28**] am was only 13.7 and patient underwent high dose steroid
course for 5 days (hydrocortisone/ fludrocortisone) that allowed
his BP to return to normal and he was weaned off levophed. GIB
and sepsis was treated as above and the pt??????s BP stabilized.
Patient while in ICU was maintained at a goal CVP of 9, with a
BP goal 90-130. With resolution of his GIB and sepsis, patient
became more hypertensive despite diuresis. His hypertension was
managed with captopril and amlodipine. Nadolol was added also
for prevention of variceal bleed. Hypertensive medications were
titrated up for further for optimal control.
.
# ID ?????? While in the MICU the pt also suffered from a ventilator
associated MRSA pneumonia which was treated with Vancomycin for
two weeks. Subsequently he developed a central line related VRE
infection resulting into sepsis, successfully treated with a
course of Linezolid of seven days after removal of the line.
During the sepsis pt intermittently required Levophed for
hypotension as above. Pt was also treated with Piperacillin and
Tazobactam for suspected SBP although a paracentesis was never
performed due to the persistently small amount of ascites after
the initial drainage during the TIPS procedure. As the pt became
afebrile and no evidence of SBP was found he was continued on
prophylactic Ciprofloxacin which was later stopped.
Echocardiogram performed on [**3-3**] did not show any evidence of
endocarditis.
.
#. Alcoholic cirrhosis: Patient with significant disease and
varices, and very poor prognosis. Hepatitis serologies were
negative. Not a transplant candidate per Hepatology service, but
needs to be reevaluated. SW consult was obtained for family
coping with poor prognosis. Patient with uptrending bilirubin
and INR throughout the inital MICU course most likely in the
context of GIB and sepsis. As the overwhole status improved and
the GIB and sepsis resolved the total bilirubin stabilized and
then slowly trended down. The pt was severly encephalopathic in
the context of the liver failure especially after the placement
of the TIPS. He was started on Lactulose to achieve [**5-20**] BM a day
and subsequently was also started in Rifaximin. Vit K was given
without substantial effect on the pt??????s coagulation factors. A
total of 40 U of Fresh frozen plasma and 9U of platelets were
given throughout the active episodes of GIB. The pt was
initially given TPN and was subsequently switched to tube
feedings through Doboff. With improving mental status the pt was
switched to oral intake and the Doboff was removed.
.
# Hypoxia/Respirator Dependance ?????? Prolonged intubation period
even after resolution of GIB and line-related sepsis was
attributed to pneumonia, atelectasis and fluid overload.
Patient was gradually diuresed with lasix prn and lasix gtt. He
was treated with Vanco/Linezolid as above. Due to long
intubation period (>2 weeks) and his persistent requirement for
PEEP, patient underwent evaluation for Tracheostomy placement by
IP. However he was able to tolerate a trial of CPAP well and
subsequently was successfully extubated on [**3-6**] only requiring
intermittent CPAP aferwards. Patient continued to require
oxygen support that was gradually weaned off along with further
diuresis and improvement in his pneumonia and atelectasis.
.
#. DM: Patient was on insulin drip while intubated. He was
converted to a sliding scale on [**3-9**] with NPH 30 units in the
morning and 10 units at night and was then further adjusted for
tight glucose control. Given his stable finger sticks, oral
agents can be restarted soon after discharge.
.
# ARF: Patient had intermittent elevated Cr during
hospitalization. DDx included hepatorenal vs prerenal. FeNa<1%,
with UNa low of 14. Patient was started on octreotide and
midodrine with mild improvement of renal function. Patient
tolerated diuresis well with good UO, his max Cr was 1.4.
Midodrine was d/c along with levophed as patient renal function
improved. ARF subsequently resolved.
.
# # L arm inabilitiy to elevate: most likely axillar neuropathy
from fall prior to presentation. No further diagnostic tests
necessary at this point. Will need aggressive PT. The pt will
follow up with neurology clinic as an outpatient.
Medications on Admission:
pervacid
metoformin
glucotrol
lisinopril
lactulose
lexapro
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
3. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) appl
Ophthalmic once a day as needed.
4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) patch
Transdermal once a day.
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO 2X
(TIMES 2).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
15. Lactulose 10 g/15 mL Solution Sig: Thirty (30) ML PO QID (4
times a day) as needed for titrate to [**4-18**] bowel movements per
day.
16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty
(30) Units Subcutaneous qam.
17. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fifteen
(15) Units Subcutaneous qpm.
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
sliding scale Subcutaneous qachs.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Variceal bleed
Respiratory failure
Ventilator associated pneumonia
Line related sepsis
Alcoholic cirrhosis
Hypertension
Esophageal and gastric varices
Diabetes Mellitus
Acute renal failure
Discharge Condition:
Stable, AAOx3, breathing at baseline
Discharge Instructions:
Please let the nurses or doctors at the [**Name5 (PTitle) **] center
know if you experience any lightheadedness, dizziness, nausea,
vomiting, blood in your stool or dark stools or any other
concerns.
.
Please take all medications as instructed
Followup Instructions:
Please follow up with the liver clinic; you have an appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2150-4-1**] 1:30pm. Call them at
[**Telephone/Fax (1) 56990**] to register.
Please follow up with neurology clinic for your left shoulder
pain. You have an appointment with Dr. [**Last Name (STitle) 575**] [**Name (STitle) **] on
[**2150-4-1**] at 4pm, on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Please
call them at [**Telephone/Fax (1) 44**] to register.
Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks after you are
discharged from rehab.
ICD9 Codes: 0389, 5849, 4280, 2875, 4019 | [
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train_44109 | completed | cfa58be5-d2ea-40e8-866a-773da754e23f | Medical Text: Admission Date: [**2146-4-14**] Discharge Date: [**2146-4-19**]
Date of Birth: [**2074-10-23**] Sex: M
Service: [**Location (un) 259**]
CHIEF COMPLAINT: Hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man
with a past medical history as noted below, who presented to
the Emergency Department with complaints of several weeks of
progressive weakness and fatigue. On the morning of
admission, the patient states that he developed mild "slow
vertigo" that was worse when sitting up. The patient states
that he had a similar episode one month prior to admission
that was attributed to dehydration from diarrhea; the patient
was hospitalized from [**3-18**] through [**2146-3-22**] for
this problem. [**Name (NI) **] has also noted slurred speech for about
three weeks prior to admission, which his family attributes
to cyclobenzaprine and Percocet use.
He otherwise, denied fever, chills, headache, tinnitus,
hearing loss, visual changes, chest pain, shortness of
breath, or sensory loss. In the Emergency Department, the
patient received hydrocortisone 100 mg IV, 1 gram of
Vancomycin IV, ceftriaxone, Flagyl, and 2 liters of normal
saline IV.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis.
2. Coronary artery disease status post five vessel CABG in
[**2128**].
3. Congestive heart failure with an ejection fraction of 20%
and moderate mitral regurgitation.
4. Ischemic stroke in [**2141**].
5. Left carotid endarterectomy in [**2142-8-29**].
6. Diverticulitis.
7. Colovesicular fistula.
8. Bilateral knee replacements.
9. Left inguinal herniorrhaphy.
10. Asbestosis.
11. Staphylococcal osteomyelitis in [**2140-12-29**].
12. Left hip replacement.
13. Cavitary pulmonary aspergilloma.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Prednisone 6 mg po q day.
2. Aspirin 81 mg po q day.
3. Alendronate 70 mg po q Monday.
4. Ipratropium two puffs qid.
5. Lisinopril 10 mg po q day.
6. Atorvastatin 20 mg po q day.
7. Furosemide 20 mg po q day.
8. Levofloxacin 250 mg po q day.
9. Ranitidine 150 mg po q day.
10. Voriconazole 200 mg po bid.
11. Metoprolol 25 mg po bid.
12. Cyclobenzaprine 10 mg po q day.
13. Acetaminophen 650 mg po q4-6h prn.
14. Percocet.
SOCIAL HISTORY: The patient has a 100 pack year smoking
history, but he quit smoking cigarettes five years prior to
admission. He denies any history of alcohol abuse. He
worked in the Navy, which is where he had asbestos exposure.
He walks with assistance at home, and he is on 2 liters of
oxygen by nasal cannula at home. His daughter is actively
involved in his medical care.
FAMILY HISTORY: [**Name (NI) **] mother died of bone cancer. His
father died of lung cancer.
PHYSICAL EXAMINATION: On initial physical examination, the
patient's temperature was 96.6, heart rate 80, blood pressure
96/56, respiratory rate 24, and oxygen saturation 100% on 1.5
liters of oxygen by nasal cannula. The patient was a thin,
elderly, cachectic gentleman in no acute distress. His
sclerae were clear bilaterally, pupils were 4 mm and equally
reactive to light bilaterally, his oropharynx was dry, and he
had no jugular venous distention. He had no wheezes, he had
empty breath sounds over the right upper lung fields, and had
bibasilar crackles. He had no rhonchi. His heart was a
regular, rate, and rhythm, there were normal S1, S2 heart
sounds. There was a 1-2/6 early systolic ejection murmur
heard best at the right upper sternal border, no S3, S4 heart
sounds, and evidence of a prior CABG scar. His abdomen was
soft, nontender, nondistended, there were normoactive bowel
sounds. He had no hepatosplenomegaly. There was no rebound
or guarding, and he had a lower abdominal scar. There was no
lower extremity edema. He had palpable dorsalis pedal pulses
bilaterally, and evidence of chronic rheumatoid arthritis
deformations of his hands bilaterally. He was alert and
oriented times three, had occasional slurred speech, cranial
nerves II through XII were intact, strength was [**5-2**]
throughout, he had no focal sensory deficits, and his deep
tendon reflexes were 1+ throughout.
On initial laboratory evaluation, the patient's white count
was 8.6 (with a differential of 83% neutrophils, 2% bands, 5%
lymphocytes, and 9% monocytes), hematocrit of 29.9, and
platelets of 203,000. Initial serum chemistries demonstrated
a sodium of 130, potassium 5.5, chloride 101, bicarbonate 18,
BUN 61, creatinine 2.3 (baseline creatinine is 1.3-1.5), and
glucose of 108, his calcium is 8.8, magnesium 2.3, and
phosphate 4.3. His INR was 1.1 and his PTT was 24.3, ALT was
8, AST 24, amylase 33, total bilirubin 0.4, and his albumin
was 3.2. His initial urinalysis demonstrated a specific
gravity of 1.020 and was otherwise negative. Of note, the
patient's initial CK was 60, but his initial troponin-I was
10.
His initial electrocardiogram demonstrated normal sinus
rhythm at 80 beats per minute, intraventricular conduction
delay, normal axis, minimal ST segment depressions in leads
V4 through V6; his ST segment changes were slightly different
compared with an electrocardiogram dated [**2146-3-18**].
On initial chest radiograph, he had persistent chronic
changes, no evidence of failure, and no acute cardiopulmonary
process.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: After the initial troponin value of 10,
the patient subsequently had troponin values of 15 and then
9. Given his elevated troponins in the setting of
hypotension on admission, the patient was felt to have had a
recent NSTEMI in the setting of low effective circulating
volume. In the absence of recent or active chest pain or
anginal symptoms, and given the patient's acute renal
failure, it was thought that this myocardial infarction most
likely occurred within seven days prior to admission.
Because he appeared to have a low effective circulating
volume on admission, the patient was aggressive rehydrated
with intravenous fluids with a subsequent good response in
his blood pressure.
In order to evaluate whether or not the patient had any new
clinically significant ischemic changes resulting from his
NSTEMI, a transthoracic echocardiogram was performed on
hospital day two. This study demonstrated that the left
atrium is mildly dilated, the left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal, there is severe global left ventricular hypokinesis.
The right ventricular cavity is markedly dilated. There is
severe global right ventricular free wall hypokinesis, the
aortic root is moderately dilated, and there were no
significant valvular abnormalities noted.
Overall, compared with the report of a prior transthoracic
echocardiogram done on [**2142-6-27**], no major changes were
found on this transthoracic echocardiogram.
In order to further evaluate the patient's NSTEMI, he had a
small P-MIBI on the day prior to discharge. During this
study, he had no angina or ischemic electrocardiogram
changes. The nuclear portion of this study demonstrated a
moderate, fixed defect in the inferior myocardial wall,
enlarged left and right ventricles, and global hypokinesis
with a left ventricular ejection fraction of 18%. When
compared to the prior study of [**2142-8-27**], there was
significant interval deterioration.
In terms of the patient's hypotension on admission, by
hospital day two, his standing metoprolol dose was restarted.
On hospital day three, his ACEI was reinstituted, and on the
day prior to discharge, he was restarted on his standing
furosemide dose for his significant congestive heart failure.
2. Renal: The patient's renal function improved dramatically
following aggressive fluid resuscitation. On the day prior
to discharge, his serum creatinine was 1.0; on the day of
discharge it was 1.2 following the reinitiation of therapy
with furosemide.
3. Endocrine: Given the patient's presentation with relative
hyponatremia, hyperkalemia, and hypotension, there was
consideration given to the possibility of adrenal
insufficiency, especially given the patient's prolonged
steroid use. Of note, his prednisone dose had reportedly
recently been changed from 7 mg daily to 6 mg daily. During
the first day of his hospitalization, the patient received
stress dosed steroids; he was changed to his standing
prednisone dose of 6 mg daily on hospital day two.
On hospital day three, a random morning cortisol level was
checked; this level subsequently returned at 7.6. In talking
with the Endocrine Department, it was felt that this level
was difficult to interpret in the face of the patient's
chronic prednisone therapy. In order to further evaluate for
the possibility of adrenal insufficiency, a cortisol level
was drawn prior to the administration of the patient's
morning prednisone dose on the morning of discharge.
However, the patient was no longer orthostatic at the time of
discharge, and Dr. [**Last Name (STitle) 1266**] will follow up on the results of
this cortisol level on an outpatient basis.
4. Infectious Diseases: As noted above, the patient had MSSA
osteomyelitis in late [**2139**] and early [**2140**]. At that time, the
osteomyelitis was found to including the patient's left hip,
which was subsequently replaced. According to OMR notes, it
seemed possible that the patient may have had an occult
source of infection at the time that his left hip was
replaced. Because of this possibility, the decision was made
in conjunction with the Department of Infectious Diseases at
that time, to continue the patient on life-long antimicrobial
therapy with levofloxacin. His levofloxacin was therefore
continued during this hospitalization.
In addition, the patient was recently noted to have a
cavitary pulmonary aspergilloma, for which he is continuing
to receive long-term therapy with voriconazole. Of note, the
patient's white blood cell count was mildly elevated at 11.6
on the date of discharge; Dr. [**Last Name (STitle) 1266**] will also follow this
level on an outpatient basis.
5. Hematology: The patient's hematocrit trended down over
the first three days of his hospitalization, such that his
hematocrit was 25.3 on hospital day three. Given his
extensive history of coronary disease, the patient was
therefore transfused 2 units of packed red blood cells on
hospital day three. His hematocrit subsequently increased to
a level of 34; it was 32.3 on the date of discharge. Iron
studies obtained prior to these transfusions were most
consistent with a picture of anemia of chronic disease,
although the patient's iron level was normal at 89.
6. Neurology: By hospital day four, the patient began
complaining of a severe right sided, periauricular headache.
The etiology of this headache was unclear, but the patient
did have a negative head CT scan at the time of admission.
This headache was treated supportively, and on the day of
discharge, the patient found that certain movements were able
to alleviate the headache.
7. Gastrointestinal: The patient's alkaline phosphatase
level was found to be elevated in the absence of any nausea,
vomiting, or abdominal pain. This level will continue to be
followed on an outpatient basis. Also of note, the patient
had a bedside swallowing evaluation during this
hospitalization, during which the Department of Speech
Pathology felt that the patient could continue with his
current diet.
DISCHARGE CONDITION: Stable.
DISCHARGE PLACEMENT: Home with services.
DISCHARGE DIAGNOSES:
1. Hypotension.
2. Non-ST elevation myocardial infarction.
3. Systolic congestive heart failure.
4. Headache.
5. Hypovolemia.
Please see the past medical history list for the remainder of
the [**Hospital 228**] medical problems.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po q day.
2. Alendronate 70 mg po q Monday.
3. Ipratropium two puffs qid.
4. Levofloxacin 250 mg po q day.
5. Ranitidine 150 mg po bid.
6. Voriconazole 200 mg po bid.
7. Atorvastatin 10 mg po q day.
8. Metoprolol 25 mg po bid.
9. Celicoxib 200 mg po bid.
10. Furosemide 20 mg po q day.
11. Prednisone 6 mg po q day.
12. Lisinopril 10 mg po q day.
13. Acetaminophen 325-650 mg po q4-6h prn pain.
DISCHARGE INSTRUCTIONS: The patient was instructed to call
Dr. [**Last Name (STitle) 1266**] on the day following discharge to arrange for a
follow-up appointment with him by [**Last Name (LF) 2974**], [**2146-4-29**]. He
was also instructed to maintain all previously arranged
medical appointments.
[**Known firstname **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2146-4-19**] 18:47
T: [**2146-4-22**] 06:40
JOB#: [**Job Number 9510**]
ICD9 Codes: 5849, 4280, 2765, 2761, 2767 | [
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train_44114 | completed | a23749a9-efc5-4b40-8d61-1accdbec30f6 | Medical Text: Admission Date: [**2117-4-13**] Discharge Date: [**2117-6-3**]
Date of Birth: [**2117-4-13**] Sex: F
Service: Neonatology
HISTORY: This infant is a 920 gram 28-2/7 weeks preterm
female admitted to the Intensive Care Unit for management of
prematurity. She was born to a 30-year-old gravida 1, para 0
mother. Prenatal screens: Blood type O positive, antibody
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, and group beta Strep status
unknown.
This pregnancy was complicated by poor fetal growth. The
mother underwent frequent monitoring. Last week
oligohydramnios was noted. Today mother presented with
decreased fetal movement, although mother reports decreased
movement x1 week. Initial biophysical profile was [**5-4**],
repeat later was [**7-4**]. AFI [**6-1**]. Decreased end diastolic flow
was also noted. Betamethasone was started. The mom received
one dose. During fetal monitoring, multiple decelerations,
prompting delivery by cesarean section. There was no
maternal fever. Membranes were ruptured at time of delivery
with some possible meconium stained amniotic fluid. Infant
with a spontaneous cry. She was given CPAP and intubated
with a 2.5 endotracheal tube in the delivery room. Apgar
scores were six at one minute and seven at five minutes of
age.
She was shown to her parents and then transferred to the
Newborn Intensive Care Unit. Placental appearance in the
delivery room concerning with multiple clear cysts, firm
thrombotic areas in the vessels. Otherwise, placenta soft
and friable. Small umbilical cord.
PHYSICAL EXAMINATION: Weight 920 grams (25th percentile).
Length 37.5 cm (50th percentile), head circumference 26 cm
(50th percentile). Infant is pink, intubated, and active.
Nondysmorphic. Anterior fontanel is soft and flat. Ears are
normal and set with no anomalies. Palate intact. Neck is
supple. Lungs with poor aeration, but equal bilaterally.
Cardiovascular: Heart regular, rate, and rhythm, no murmur,
+2 femoral pulses. Abdomen is soft, positive bowel sounds,
no hepatosplenomegaly. Three vessel umbilical cord.
Genitourinary: Normal preterm female. Patent anus. No
sacral anomalies. Hips stable. Extremities pink and well
perfused.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: [**Known lastname 15406**] was intubated in the delivery room
for poor respiratory effort. She received a total of two
days of Survanta, then extubated to CPAP within 24 hours of
age. She weaned to nasal cannula O2 on day of life, and then
finally, to room air on day of life four. She was started on
caffeine citrate on day of life for apnea of prematurity.
The caffeine was discontinued on day of life 28. She has had
no recent apneic spells. Her last episode was on day of life
38.
2. Cardiovascular: [**Known lastname 15406**] received one normal saline bolus
shortly after admission to the Newborn Intensive Care Unit
for decreased blood pressure. Her blood pressure has
remained stable for the remainder of her hospitalization. A
soft murmur was noted on day of life 10, a preliminary
cardiac evaluation revealed normal four extremity blood
pressures, a normal chest x-ray, and a normal 12-lead
electrocardiogram.
3. Fluids, electrolytes, and nutrition: IV fluids at D10W at
100 cc/kg were started upon admission to the Newborn
Intensive Care Unit. She received one bolus of D10W for a
D-stick of 35 shortly after admission to the NICU. No
further hypoglycemic episodes throughout her hospitalization.
Enteral feeds were started on day of life four. She advanced
to full volume feeds of 150 cc/kg by day of life 12 without
incident. Maximum caloric density of breast milk 30 calorie
with ProMod. No issues of feeding intolerance. Discharge
weight 2,125 grams. Discharge length 43.8 cm and discharge
head circumference 31 cm.
4. GI: Peak bilirubin on day of life one was a total
bilirubin of 8.0 with a direct of 0.3. She was started on
phototherapy at that time. Phototherapy was discontinued on
day of life six with a rebound bilirubin on day of life seven
of 2.7/0.5.
5. Heme: [**Known lastname 15406**] did not receive any blood products during
her hospitalization. Last hematocrit and retic on [**6-2**]
were 27.2 and a reticulocyte count of 14.0.
6. ID: A complete blood count with differential and a blood
culture were sent upon admission to the Newborn Intensive
Care Unit. A complete blood count showed white blood cell
count of 4700, hematocrit of 45, platelet count of 205,000
with 25% neutrophils, and 0% bands. The blood culture was
negative. She received a seven day course of ampicillin and
gentamicin for leukopenia. Her lumbar puncture was normal.
She received a five day course of erythromycin ointment to
both eyes for purulent eye drainage from day of 10 to day of
life 15. No further ID issues during her hospitalization.
7. Neurology: Head ultrasound on day of life two, day of
life eight, and day of life 28 were all normal.
8. Sensory: A hearing screen was performed with an automated
auditory brain stem responses. She passed in both ears on
[**6-2**].
Ophthalmology: [**Known lastname 48278**] eyes were most recently examined
on [**5-26**] revealing ROP Stage I zone 3 6 o'clock hours in
the left eye. A follow-up exam is recommended two weeks from
the last examination.
Psychosocial: [**Hospital1 69**] Social
Work has been involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) **]. Both parents very loving
and involved in the care of this infant.
CONDITION ON DISCHARGE: Growing premature infant feeding
well with mature respiratory pattern.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] of [**Hospital 17566**]
Pediatrics, phone #[**Telephone/Fax (1) 49598**].
CARE RECOMMENDATIONS: Feeds at discharge: Breast feeding
with supplements of breast milk enriched to 26 calories per
ounce with Enfamil powder and corn oil.
MEDICATIONS: Poly-Vi-[**Male First Name (un) **] and ferrous sulfate.
CAR SEAT POSITION SCREENING: [**Known lastname 15406**] passed her car seat
test on [**6-2**].
STATE NEWBORN SCREEN: Last state newborn screen was done on
[**5-7**], and no abnormal results were reported.
IMMUNIZATIONS RECEIVED: [**Known lastname 15406**] received her first
hepatitis B vaccine on [**6-2**].
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: 1) Born at less than 32 weeks, 2) born between 32
and 35 weeks with plans for daycare during RSV season, with a
smoker in the household, or with preschool siblings, or 3)
with chronic lung disease. Influenza immunization should be
considered annually in the fall for preterm infants with
chronic lung disease once they reach six months of age.
Before this age, the family and other caregivers should be
considered for immunization against influenza to protect the
infant.
FOLLOW-UP APPOINTMENTS: [**Known lastname 15406**] will be followed by
Ophthalmology at [**Hospital3 1810**]. She will be followed
by Dr. [**Last Name (STitle) 36137**]. This appointment will be arrnged by her
mother.x
DISCHARGE DIAGNOSES:
1. Prematurity at 28-2/7 weeks gestation.
2. Respiratory distress syndrome.
3. Presumed sepsis.
4. Hyperbilirubinemia.
5. Apnea of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Name8 (MD) 37391**]
MEDQUIST36
D: [**2117-6-3**] 00:14
T: [**2117-6-3**] 05:58
JOB#: [**Job Number 49599**]
ICD9 Codes: 769, 7742, 0389 | [
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train_43665 | completed | d99d0f8c-2877-4364-b84b-dfef46e94461 | Medical Text: Admission Date: [**2200-10-3**] Discharge Date: [**2200-10-13**]
Date of Birth: [**2160-2-16**] Sex: M
Service: MEDICINE
Allergies:
Sulfasalazine / Tape [**12-22**]"X10YD / Lactose / Optiray 350
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
40M s/p liver transplant 4 months ago on Rapamune and Cellcept
transferred by ambulance from [**Hospital Ward Name **] after becoming
unresponsive. Patient had been called from home after routine
labs drawn 5 days prior to hyponatremia with sodium of 122.
[**Name (NI) **] mother states that he had an episode of staring into
space yesterday. Today, prior to having labs drawn, the patient
crumpled to the ground and became unresponsive. Fingerstick
170s.
.
On arrival to ED, patient is unresponsive and rigid. Afebrile,
no outright seizure activity but eyes are deviated. Tachycardic
and normotensive. Reportedly was rigid for periods of time mixed
in with delerium. Rigidity and mental status improved after
Ativan.
.
He had an LP and was given vanc, ceftriaxone, acyclovir,
ampicillin, 2LNS. A head CT showed no acute intracranial
process. CXR was negative. He was seen by neurology who
recommened EEG. Also seen by liver and transplant surgery.
.
On arrival to the ICU, he is shivering and reports feeling
unwell since switched from the tacro to rapammune. He states
that since this change, he has had chills, mouth sores and
worsening diarrhea.
Past Medical History:
1. Ulcerative colitis s/p subtotal colectomy [**2196**] with chronic
diarrhea
2. Primary sclerosing cholangitis, liver cirrhosis complicated
by
cirrhosis, ascites, and varices s/p banding
3. Esophageal varices s/p banding
PSH: ABO incomaptible liver transplant [**2200-4-18**]
Exploratory laparotomy, takedown jejunojejunostomy and liver
biopsy [**2200-4-27**]
Social History:
He is single and heterosexual; He is currently not working and
is on disability. He lives at home with parents. No alcohol or
drugs.
Family History:
His father has [**Name (NI) 4522**] disease. There is no known family history
of colon cancer. He does not smoke cigarettes or use NSAIDs. He
is not certain whether stress makes his condition worse. Both
parents are well. He has no siblings.
Physical Exam:
Vitals: 99.3, 97.5, 119/75, 86, 17, 98RA
General:AAOx3 in NAD, not making eye contact. Answering
questions appropriately. Very flat affect
HEENT: PEERLA, MMM, no lymphadenopathy, temporal wasting
Heart: RRR, no MRG appreciated
Lungs: CTAB
Abdomen: Thin, tympanitic but no shifting dullness, multiple
light colored striae, and scars are well healed. +BS, nontender,
nondistended, no rebound or gurading
Extremities: No peripheral edema, 2+DP pulses biltareally
Neurological: AA0x3, no asterixis. CN II-XII intact, strenght
[**4-24**] bilaterally UE and LE.
Pertinent Results:
Admission labs:
[**2200-10-3**] 10:30AM BLOOD WBC-6.1 RBC-3.80* Hgb-12.1* Hct-34.1*
MCV-90# MCH-31.9 MCHC-35.5* RDW-14.2 Plt Ct-453*
[**2200-10-3**] 10:30AM BLOOD Neuts-47* Bands-10* Lymphs-31 Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2200-10-3**] 10:30AM BLOOD Glucose-172* UreaN-59* Creat-3.1* Na-124*
K-3.7 Cl-80* HCO3-16* AnGap-32*
[**2200-10-3**] 10:30AM BLOOD ALT-28 AST-63* AlkPhos-136* TotBili-0.3
DirBili-0.1 IndBili-0.2
[**2200-10-3**] 10:30AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.7*
[**2200-10-3**] 10:39AM BLOOD Lactate-7.0* Na-122* K-3.5
[**2200-10-3**] 01:43PM BLOOD Lactate-2.5*
[**2200-10-3**] 01:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-5
Lymphs-80 Monos-15
[**2200-10-3**] 01:00PM10/16 Stool O&P, viral Cx: pending
[**10-5**] Stool C. diff: negative
[**10-5**] Blood Cx: pending
[**10-5**] CMV VL: pending
[**10-4**] Blood Cx: pending
[**10-3**] Stool Cx/C. diff: negative
[**10-3**] Urine Cx: no growth
[**10-3**] CSF: coag neg Staph --> then no growth
ACINETOBACTER SP.. UNABLE TO IDENTIFY FURTHER.
FINAL SENSITIVITIES. sensitivity testing performed by
Microscan.
Cefepime >16 MCG/ML.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
TETRACYCLINE AND MEROPENEM SENSITIVITY TESTING
REQUESTED BY DR.
[**Last Name (STitle) **] ([**Numeric Identifier 59053**]) [**2200-10-8**].
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER SP.
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>32 R
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ 2 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TETRACYCLINE---------- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=2 S
[**10-3**] Stool studies:NO MICROSPORIDIUM SEEN. NO CYCLOSPORA SEEN.
NO SALMONELLA OR SHIGELLA FOUND. NO CAMPYLOBACTER FOUND. Feces
negative for C.difficile toxin A & B by EIA. NO OVA AND
PARASITES SEEN. NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CXR [**2200-10-3**]: IMPRESSION: No acute findings in the chest.
CT head [**2200-10-3**]: No evidence of acute intracranial
abnormalities.
RUQ U/S [**2200-10-3**]: 1. Patent hepatic vasculature.
2. Focal ring-down artifact in 1 or 2 bile ducts in the left
lobe of the
liver, may be due to pneumobilia vs artifact.
3. 1.3 x 1.3 x 1.1 cm echogenic focus in the peripheral right
lobe of the
liver, likely segment VII, not identified previously. Suggest
further
evaluation with MRI.
MRI Abdomen [**2200-10-5**]: 1. Discrete patchy parenchymal abnormality
in segment VI of the liver peripherally concerning for focal
area of inflammation or infection. No liquefaction or collection
identified in this region. Attention to this region on follow-up
is recommended to evaluate for evolving abscess.2. Intraluminal
splenic vein thrombus with extension of clot into the SMV-portal
vein confluence, new since prior imaging. 3. Septated minimally
complex 5mm cyst in the upper pole of the right kidney.
MRI Brain [**2200-10-8**]: 1. No evidence of intracranial
infection/abscess, as questioned clinically. 2. Decreased
conspicuity of T1 hyperintensities with the bilateral basal
ganglia previously seen on [**2200-5-1**].
Brief Hospital Course:
40 yo M s/p Liver transplant (cadaveric) in [**3-/2200**] for PSC
cirrhosis, and UC s/p colectomy who presented with diarrhea in
the setting of elevated rapamycin levels and was septic with GNR
and found to have a splenic-portal vein junction thrombus on
MRI.
.
#ACINETOBACTER sepsis- patient was admited and fond to have
sepsis, and +GNR bacteremia. He was started on daptomycin,
cefepmine and flagyl. After this was speciated and found to be
enterobacter with known sensitivies including resistance to
cefepime he was switched to cipro/flagyl and bactrim (treatment
dose). Infectious disease was consulted who recommended a MRI
given that he presented with concern for seizure and the
affinity of enterobacter for the brain. MRI showed no areas
concerning for infection. He also had an area within his liver
which was concerning for a possible liver abscess and therefore
he was continued on the flagyl for broader coverage. Per
infectious disease consult, Pt will be discharged with cipro
500mg po bid and Bactrim DS [**Hospital1 **] until [**11-1**], after which he
will resume his previous dose of Bactrim SS daily.
.
# Diarrhea: Patient had diarrhea on admission with negative
stool studies since then, including C. diff. He had a small
bowel enteroscopy on [**10-5**]; a Schatzki's ring was found in the
lower third of the esophagus. Protruding Lesions 2 cords of
grade I varices were seen in the lower third of the esophagus.
The varices were not bleeding. Pt also had sigmoidoscopy on
[**10-5**]; A few punched out ulcers with stigmata of recent bleeding
in the rectum (biopsy). No evidence of surrounding colitis was
noted. Otherwise normal sigmoidoscopy to splenic flexure. His
final biopsy showed chronic severely active colitis with
ulceration. No granulomata or dysplasia identified. CMV
negative. An anti TTG IgA (to rule out sprue) was still pending
on discharge but serum total IgA is low at 17. However, low
suspicion of sprue given high vitamin B12 and folate levels
inconsistent with malabsorption. His diarrhea / blood stool were
therefore attributed to a UC flare, and Pt's symptoms improved
w/ [**Hospital1 **] mesalamine enemas and PRN immodium, which were both
continued on discharge.
#Thrombus- patient was found to have a thrombus in splenic vein
/ portal vein junction on MRI. He was anticoagluated initially
with a heparin gtt, and ultimately switched to coumadin. This is
important so that he does not have a clot that breaks off and
block blood flow in his liver. Bridging with enoxaparin was
considered but patient states that he absolutely will not "do
needles." Pt was discharged with warfarin 3mg po daily and close
follow-up in transplant clinic, where he already has twice
weekly lab draws. He should have repeat imaging in 3 months to
document resolution of his thrombus, followed by 3 more months
of anticoagulation and then stop.
#S/p Liver transplant- Patient had elevated rapamycin levels on
admission and associated diarrhea. His sirolimus was held until
it was back in the therapeutic range and then restarted at
1mg/day. He was continued on his cellcept, bactrim and
valgancyclovir while here. His sirolimus level was low at 4.9 on
day of discharge, so it was increased back to 2mg/day on
discharge.
# hyponatremia - This was likely due to decreased po intake and
diarrhea and corrected readily with rehydration, and had
resolved after a couple of days inpatient, and was normal at the
time of discharge.
# ? seizure - He was followed by neurology. Based on history it
was eventually felt likely that his presentation represented
true seizure acitvity. He had no further suspicious episodes.
# Nutrition/ Function- patient with decrease po intake and
temporal wasting on exam. He was seen by nutrition who felt that
he would benefit from tube feedings. He had an NJ tube placed on
EGD, with fixing by IR. He tolerated his tube feeds without
problems and was counseled on foods to eat to improve his
nutritional state. He was monitored for signs of refeeding
syndrome and his phos was repleted during this time. Pt was set
up with tube feeds delivered to his home on day of discharge.
TRANSITIONAL ISSUES:
-Pt will need repeat Hct within 1 wk to ensure bleeding is
controlled.
-Pt will need regular INR checks at his biweekly draws. He
should continue anticoagulation with goal 2.5 and have repeat
imaging in 3 months to document resolution of his thrombus,
followed by 3 more months of anticoagulation and then stop.
Medications on Admission:
- ERGOCALCIFEROL (VITAMIN D2) - (Prescribed by Other Provider) -
50,000 unit Capsule - 1 Capsule(s) by mouth twice per week
- MYCOPHENOLATE MOFETIL - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day
- SIROLIMUS [RAPAMUNE] - (Dose adjustment - no new Rx) - 1 mg
Tablet -2 Tablet(s) by mouth once a day
- SODIUM POLYSTYRENE SULFONATE [KAYEXALATE] - Powder - 4 tsp
Powder(s) by mouth once a day as needed for for high potassium
level Transplant Center will call you if you need to take
- SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s) by mouth DAILY (Daily)
- TRIAMCINOLONE ACETONIDE - 0.1 % Paste - apply to affected
areas twice a day
- VALGANCICLOVIR [VALCYTE] - (Dose adjustment - no new Rx) - 450
mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
- CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] -
(Prescribed by Other Provider; Dose adjustment - no new Rx) -
600 mg-400 unit Tablet - one Tablet(s) by mouth twice a day
- LYSINE - 600 mg Tablet - 1 Tablet(s) by mouth twice a day
Discharge Medications:
1. Tube feeds
sig: Isosource 1.5 or equivalent at 60ml/hr via pump and
supplies
refills: 3
2. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO twice per week.
3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
twice a day.
4. sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. sodium polystyrene sulfonate Powder Sig: Four (4) tsp PO
once a day as needed for high potassium: Transplant Center will
call you if you need to take this medication.
6. triamcinolone acetonide 0.1 % Ointment Sig: apply to affected
areas Topical twice a day.
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a
day.
8. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
9. lysine 600 mg Tablet Sig: One (1) Tablet PO twice a day.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Take through [**2200-11-1**].
Disp:*38 Tablet(s)* Refills:*0*
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day): Take through [**2200-11-1**] then start
taking 1 single strength tablet daily as before.
Disp:*76 Tablet(s)* Refills:*0*
12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO once a day: Start taking this on [**2200-11-2**].
13. mesalamine 4 gram/60 mL Enema Sig: One (1) enema Rectal [**Hospital1 **]
(2 times a day).
Disp:*60 enema* Refills:*0*
14. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*60 Capsule(s)* Refills:*0*
15. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Dosing will be managed by [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the transplant
center.
Disp:*30 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please check CBC, chem 10, and INR twice weekly and fax results
to [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the Transplant Center. Fax: ([**Telephone/Fax (1) 12146**].
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary: Enterobacter sepsis, splenic vein thrombosis,
ulcerative colitis flare, malnutrition, hyponatremia
Secondary: S/p liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 13029**],
.
It was a pleasure caring for you while you were here at [**Hospital1 18**].
You were admitted because you were found unconscious. This was
likely from electrolyte abnormalities in your blood which have
been corrected. You were also found to have a bacterial
infection in your blood which we are treating with antibiotics.
.
You were found to have a blood clot in one of the vessels near
your liver. We are treating this with a blood thinner called
warfarin (Coumadin) which you will need to take for at least the
next few months. This medication requires regular blood tests
which will be managed by [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in the transplant center.
.
You were found to be very malnourished. We placed a feeding tube
through your nose to give you a sufficient level of nutrients
and calories. You will continue with the tube feeds at home but
should eat as well.
.
Prior to your admission you were having a lot of diarrhea. We
performed a flexible sigmoidoscopy and endoscopy which showed
several ulcers in your rectum and inflammation consistent with
your ulcerative colitis. We are treating this with mesalamine
enemas and the diarrhea is improving.
.
We made the following changes to your medications:
- START Bactrim (sulfamethoxazole-trimethoprim) 2 double
strength tablets twice daily through [**2200-11-1**]. On [**2200-11-2**] start
taking Bactrim 1 single strength tablet daily as you were
before.
- START Ciprofloxacin 500mg twice daily through [**2200-11-1**]
- START Mesalamine enemas twice daily
- START Loperamide (Immodium) four times daily as needed for
diarrhea
- START Warfarin (Coumadin) 3mg daily. You will have twice
weekly blood draws and [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] will tell you when to adjust
the dose.
Followup Instructions:
Department: TRANSPLANT
When: WEDNESDAY [**2200-10-22**] at 9:40 AM
With: TRANSPLANT [**Hospital 1389**] CLINIC [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2200-10-14**]
ICD9 Codes: 2761 | [
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train_44236 | completed | 8afc6142-c05a-466e-8ff1-4b51167e2254 | Medical Text: Admission Date: [**2174-7-2**] Discharge Date: [**2174-7-14**]
Date of Birth: [**2118-1-11**] Sex: F
Service: MEDICINE
Allergies:
morphine
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
SOB/COPD
Major Surgical or Invasive Procedure:
Mechanical Intubation
Central line placement right femoral and right IJ
Arctic Sun s/p PEA arrest
History of Present Illness:
56 yo F with PMH COPD and asthma who presented to OSH with
increasing SOB x 3d. Per family, despite report of SOB, she was
doing relatively fine until the day of admission, when she
developed N/V/D. Daughter came over to help transport pt to ED
and says at that time she was c/o feeling like she "couldn't
breathe" and having sweats. Called paramedics who took patient
to OSH. At OSH, pt was somnolent and minimally responsive. She
was trialed on BiPAP and then intubated for resp distress and
airway protection [**1-6**] AMS. After intubation her pressures
dropped to 80s systolic and she was started on a levophed drip
via EJ peripheral line and sedated with propofol. A CXR showed a
LLL consolidation, so she was started on azithro/CTX and
solumedrol and given 2L IVF. Labs significant for Na 141, K 3.8,
bicarb 31, AG 9, Cr 1.3, lactate 2.2, LFTs WNL, INR 1.04, WBC
25.5, Hct 41.9, Plt 218She was transferred to [**Hospital1 18**].
At [**Hospital1 18**] she triggered on arrival for O2 sat 65%, though this
was thought to be inaccurate pulse ox and first vital set in ED
records noted to be 137, 68/55, 16, 99% ETT. Labs significant
for WBC 18.8 (84% PMN), Hct 38.3, plats 203, Cr 1.6 (CHEM-7
otherwise unremarkable). U/A neg with 23 hyaline casts. Patient
had no prior records and baselines unknown. CXR showed LLL PNA.
She was broadened to vanc/cefepime and the propofol was weaned.
A right IJ was placed and she was continued on levophed (at 4.5
upon transfer) with fentanyl/midaz for sedation. Pressures
improved to 92/57 with pressors. She was tachy to 130s on
arrival. On transfer, HR 115, 92/57, 96% on CMV. She was sent
for CTA to r/o PE on way up to MICU floor.
On arrival to MICU, VS 99.5, 111, 88/55, 16, 100% CMV. Shortly
after arrival to MICU, pressures dropped and pt became
pulseless. Pt noted to have high auto-PEEP of 23 prior to
arrest. A code blue was called and chest compressions started
immediately. Rhythm check was performed and pt noted to be in
PEA arrest. Pt was coded for approx. 10 minutes after which time
pulse was regained. During that time period she received 2 amps
of epi, 2 amps of bicarb, and started on an epi drip. Labs prior
to arrival in MICU revealed unremarkable electrolyte panel.
Decreased BS noted on left both before and during code, likely
[**1-6**] to LLL PNA. Pt was very difficult to ventilate and there was
concern for large PTX, however, this was not seen on CXR. CTA
was negative for PE. Echo performed at bedside during code did
not show pericardial effusion. Repeat echo after code showed
global hypokinesis. Etiology was never identified but most
likely explanation for arrest was thought to be [**1-6**] worsened
resp failure and subsequent acidosis. Immediately after code we
were unable to assess mental status since pt was already heavily
sedated. Arctic Sun protocol was initiated and pt was paralyzed
with cisatrocurium. She was on three pressors after
stabilization - levophed, epinephrine, and neosynephrine with
pressure 102/59, HR 105, 100% on CMV.
Review of systems: unable to obtain. Sick contacts - baby
granddaughter with h/o MRSA with whom she has frequent contact
Past Medical History:
COPD (emphysema) - diagnosed 3 years ago, intubated at that time
for 2 days, on 3L O2 at home
asthma
anxiety
benign ovarian tumor s/p resection [**2174-5-6**]
Social History:
Lives at home with family. No pets. Former smoker, quit 3 years
ago.
Family History:
NC
Physical Exam:
Admission Physical
Vitals: T:99.0 BP: 130/75 P: 120 R: 17 18 O2: 95% 2L NC
General: Alert, oriented X 3 male in no acute distress ,
speaking in full sentences.
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rhythm,tachycardic, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: left insp. crackles, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley placed
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge Physical
Physical Examination
General: Awake, alert, able to sit up with minimal assistance,
pleasant, occasional cough
HEENT/Neck: MMM, clear oropharynx, no scleral icterus
Lungs: few scattered wheezes, no rhales, decreased air movement
bilaterally
Cardiac: Regular, no gallops, rubs
Abdomen: Soft, non-distended, non-tender, bowel sounds present
Extremities: No edema
Neuro: Awake, alert, appropriate. Able to sit up with minimal
assistance.
Pertinent Results:
Admission Labs
[**2174-7-2**] 10:49PM TYPE-[**Last Name (un) **] PO2-53* PCO2-77* PH-7.10* TOTAL
CO2-25 BASE XS--7
[**2174-7-2**] 10:49PM LACTATE-3.1*
[**2174-7-2**] 10:44PM TYPE-ART PO2-162* PCO2-74* PH-7.14* TOTAL
CO2-27 BASE XS--5
[**2174-7-2**] 10:19PM TYPE-ART PO2-365* PCO2-99* PH-7.02* TOTAL
CO2-28 BASE XS--8 INTUBATED-INTUBATED
[**2174-7-2**] 10:06PM TYPE-CENTRAL VE PO2-73* PCO2-129* PH-6.95*
TOTAL CO2-31* BASE XS--8
[**2174-7-2**] 10:06PM LACTATE-4.4*
[**2174-7-2**] 09:54PM GLUCOSE-211* UREA N-20 CREAT-1.5* SODIUM-142
POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12
[**2174-7-2**] 09:54PM CK(CPK)-124
[**2174-7-2**] 09:54PM CK-MB-4 cTropnT-<0.01
[**2174-7-2**] 09:54PM CALCIUM-6.8* PHOSPHATE-5.3* MAGNESIUM-1.9
[**2174-7-2**] 09:54PM WBC-23.8* RBC-3.17* HGB-10.0* HCT-31.1*
MCV-98 MCH-31.4 MCHC-32.0 RDW-13.6
[**2174-7-2**] 09:54PM PLT COUNT-174
[**2174-7-2**] 09:54PM PT-17.1* PTT-65.0* INR(PT)-1.6*
[**2174-7-2**] 08:05PM TEMP-36.7 RATES-/14 TIDAL VOL-400 PEEP-5
O2-50 PO2-94 PCO2-65* PH-7.17* TOTAL CO2-25 BASE XS--5
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2174-7-2**] 08:05PM O2 SAT-95
[**2174-7-2**] 06:24PM TYPE-ART RATES-14/0 TIDAL VOL-450 PEEP-5
O2-100 PO2-397* PCO2-61* PH-7.22* TOTAL CO2-26 BASE XS--3
AADO2-251 REQ O2-50 INTUBATED-INTUBATED VENT-CONTROLLED
[**2174-7-2**] 06:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2174-7-2**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2174-7-2**] 06:15PM URINE HYALINE-23*
[**2174-7-2**] 06:15PM URINE MUCOUS-FEW
[**2174-7-2**] 06:00PM GLUCOSE-98 UREA N-19 CREAT-1.6* SODIUM-145
POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-24 ANION GAP-16
[**2174-7-2**] 06:00PM estGFR-Using this
[**2174-7-2**] 06:00PM CK(CPK)-143
[**2174-7-2**] 06:00PM CK-MB-4 cTropnT-0.01
[**2174-7-2**] 06:00PM WBC-18.8* RBC-4.00* HGB-12.3 HCT-38.3 MCV-96
MCH-30.8 MCHC-32.1 RDW-13.6
[**2174-7-2**] 06:00PM NEUTS-84* BANDS-11* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2174-7-2**] 06:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL
[**2174-7-2**] 06:00PM PLT COUNT-203
[**2174-7-2**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2174-7-2**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2174-7-2**] 06:00PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
[**2174-7-2**] 06:00PM URINE GRANULAR-1* HYALINE-23*
[**2174-7-2**] 06:00PM URINE MUCOUS-OCC
.
[**2174-7-12**] 07:25AM BLOOD WBC-21.2* RBC-3.28* Hgb-10.0* Hct-31.5*
MCV-96 MCH-30.4 MCHC-31.7 RDW-13.8 Plt Ct-160
[**2174-7-10**] 03:52AM BLOOD WBC-25.0* RBC-3.41* Hgb-10.3* Hct-32.0*
MCV-94 MCH-30.2 MCHC-32.2 RDW-14.0 Plt Ct-131*
[**2174-7-8**] 03:46AM BLOOD WBC-14.5* RBC-3.00*# Hgb-9.3*# Hct-28.1*
MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 Plt Ct-65*
[**2174-7-6**] 03:21PM BLOOD WBC-12.9* RBC-2.54* Hgb-7.9* Hct-24.6*
MCV-97 MCH-31.1 MCHC-32.1 RDW-13.8 Plt Ct-47*
[**2174-7-6**] 03:10AM BLOOD WBC-14.3* RBC-2.65* Hgb-8.2* Hct-25.1*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.6 Plt Ct-47*
[**2174-7-4**] 04:15AM BLOOD WBC-18.6* RBC-3.60* Hgb-11.2* Hct-34.0*
MCV-94 MCH-31.0 MCHC-32.8 RDW-14.0 Plt Ct-78*
[**2174-7-3**] 09:51PM BLOOD WBC-17.0* RBC-3.48* Hgb-10.8* Hct-33.2*
MCV-95 MCH-31.0 MCHC-32.5 RDW-14.0 Plt Ct-83*
[**2174-7-10**] 03:52AM BLOOD Neuts-95.8* Lymphs-2.2* Monos-1.7* Eos-0
Baso-0.4
[**2174-7-9**] 03:14AM BLOOD Neuts-82* Bands-5 Lymphs-0 Monos-6 Eos-0
Baso-0 Atyps-2* Metas-4* Myelos-0 Promyel-1*
[**2174-7-8**] 03:46AM BLOOD Neuts-83* Bands-1 Lymphs-3* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1*
[**2174-7-6**] 03:10AM BLOOD Neuts-90* Bands-2 Lymphs-3* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2174-7-12**] 07:25AM BLOOD Plt Ct-160
[**2174-7-10**] 03:52AM BLOOD PT-13.5* PTT-24.0* INR(PT)-1.3*
[**2174-7-9**] 03:14AM BLOOD PT-12.7* PTT-22.5* INR(PT)-1.2*
[**2174-7-8**] 03:46AM BLOOD Plt Ct-65*
[**2174-7-8**] 03:46AM BLOOD PT-12.6* PTT-22.6* INR(PT)-1.2*
[**2174-7-13**] 02:50AM BLOOD Glucose-155* UreaN-24* Creat-0.7 Na-140
K-5.0 Cl-98 HCO3-33* AnGap-14
[**2174-7-12**] 03:19PM BLOOD Glucose-233* UreaN-28* Creat-0.6 Na-141
K-4.4 Cl-96 HCO3-38* AnGap-11
[**2174-7-12**] 07:25AM BLOOD Glucose-101* UreaN-29* Creat-0.6 Na-146*
K-4.3 Cl-101 HCO3-40* AnGap-9
[**2174-7-11**] 04:12AM BLOOD Glucose-210* UreaN-33* Creat-0.8 Na-145
K-4.2 Cl-98 HCO3-42* AnGap-9
[**2174-7-9**] 03:47PM BLOOD Glucose-149* UreaN-51* Creat-1.0 Na-146*
K-3.0* Cl-98 HCO3-41* AnGap-10
[**2174-7-9**] 11:25PM BLOOD Glucose-319* UreaN-45* Creat-1.0 Na-145
K-5.4* Cl-98 HCO3-39* AnGap-13
[**2174-7-10**] 03:52AM BLOOD ALT-35 AST-25 LD(LDH)-514* AlkPhos-78
TotBili-0.9
[**2174-7-9**] 03:14AM BLOOD ALT-39 AST-38 LD(LDH)-577* AlkPhos-80
TotBili-0.5
[**2174-7-7**] 03:59AM BLOOD LD(LDH)-199 TotBili-0.1
[**2174-7-6**] 03:10AM BLOOD ALT-52* AST-17 LD(LDH)-187 CK(CPK)-134
AlkPhos-73 TotBili-0.2
[**2174-7-4**] 04:15AM BLOOD ALT-89* AST-59* LD(LDH)-252* AlkPhos-59
TotBili-0.6
[**2174-7-3**] 04:11AM BLOOD ALT-54* AST-56* AlkPhos-56 TotBili-0.7
[**2174-7-13**] 02:50AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.2
[**2174-7-12**] 03:19PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
[**2174-7-12**] 07:25AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.3
[**2174-7-11**] 04:12AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.4
[**2174-7-7**] 03:59AM BLOOD Hapto-375*
[**2174-7-3**] 11:06AM BLOOD %HbA1c-5.3 eAG-105
[**2174-7-8**] 09:15PM BLOOD Type-ART pO2-106* pCO2-53* pH-7.40
calTCO2-34* Base XS-5
[**2174-7-8**] 05:08PM BLOOD Type-ART pO2-102 pCO2-69* pH-7.29*
calTCO2-35* Base XS-3
[**2174-7-8**] 02:53PM BLOOD Type-ART Temp-37.1 Rates-/21 Tidal V-400
PEEP-0 FiO2-40 pO2-138* pCO2-50* pH-7.43 calTCO2-34* Base XS-8
Intubat-INTUBATED Vent-SPONTANEOU
[**2174-7-8**] 11:39AM BLOOD Type-ART Rates-/17 PEEP-8 FiO2-40
pO2-124* pCO2-46* pH-7.44 calTCO2-32* Base XS-6
Intubat-INTUBATED Vent-SPONTANEOU
[**2174-7-7**] 09:35PM BLOOD Type-ART pO2-124* pCO2-44 pH-7.41
calTCO2-29 Base XS-3
[**2174-7-5**] 04:11PM BLOOD Glucose-164*
[**2174-7-5**] 04:10AM BLOOD Lactate-1.6
[**2174-7-4**] 01:23AM BLOOD Lactate-3.4*
[**2174-7-3**] 08:51PM BLOOD Lactate-3.6*
[**2174-7-3**] 05:53PM BLOOD Lactate-3.8*
[**2174-7-3**] 02:10AM BLOOD Lactate-2.5*
[**2174-7-2**] 10:49PM BLOOD Lactate-3.1*
[**2174-7-2**] 10:06PM BLOOD Lactate-4.4*
TTE: IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with low normal global systolic function. Right
ventricular cavity enlargement with mild free wall hypokinesis.
Compared with the prior study (images reviewed) of [**2174-7-2**],
global left ventricular systolic function is improved. The
severity of mitral regurgitation and tricuspid regurgitation are
now reduced.
CTA Chest: 1. Dense consolidation in the left upper lobe,
consistent with pneumonia. Small parapneumonic left effusion.
Findings are superimposed on a background of emphysema.
2. No evidence of pulmonary embolism.
3. No acute findings within the abdomen or pelvis.
Brief Hospital Course:
56 year old female with PMH COPD and asthma who transferred from
OSH with LLL PNA who went into PEA arrest upon arrival to MICU
s/p resuscitation on Arctic Sun cooling protocol now extubated,
treated for strep pneumonia, and severe COPD exacerbation.
# LLL PNA-Found to have a lingular/LLL consolidation on CXR.
Grew Strep pneumomia from sputum cx. Treated with 8 days of
Ceftriaxone and Levofloxacin.
--> Will need Pneumovax on or after discharge from rehab
facility
#COPD exacerbation- Was intubated for resp failure and started
on IV steroids during whole admission which was transitioned to
oral prednisone 40 mg daily on [**7-13**]. Was also placed on standing
albuterol Q4H and Ipratroipium Q6H during the admission and is
stable on this regimen. Will need aggressive pulm rehab and
outpatient pulmonology follow up. Has not been on BIPAP since
[**7-10**] which she intermittently needed since extubation on [**7-8**].
Will benefit from formal sleep eval. Goal oxygen sat should be
90-94% given severe COPD. Placed on Bactrim prophylaxis, home
pantoprazole and started calcium and vitamin D.
--> Please slow taper prednisone but should not be discontinued
until followed by pulmonology due to severity of her asthma and
her history on always being on prednisone.
#Constipation-Severe until [**7-10**] when it was resolved with
aggressive bowel reg of lactulose, senna, Colace and bisacodyl.
Now having florid bowel movements.
# Leukocytosis: s/p treatment for PNA. [**Month (only) 116**] be secondary to left
shift from steroids. CXR improved. No fevers. Lines pulled but
WBC count stable at approx. 20 for days.
# Thrombocytopenia: likely ceftriaxone induced, Hit ab negative,
now resolved.
# Anemia: Hemolysis labs negative. guaiac stools neg. Likely
marrow suppression from medications vs acute illness, stable Hct
at approx. 30.
# hypernatremia: at times has been mildly hypernatremic to 148,
resolved with oral water intake, with normal sodium level on [**7-13**]
#Hyperglycemia- start 8 units of Lantus, and sliding scale.
Likely due to IV steroids. Running low 100s. will adjust dosing
as needed ,Please monitor sugar as steroids are weaned off as
want to avoid hypoglycemia.
--> Please monitor her sugars and decrease lantus as needed.
She did not require insulin prior to her hospital stay on higher
dose steroids.
# Nutrition: Was receiving tube feeds through NG tube because of
failed speech and swallow eval. On [**7-13**] passed a second speech
and swallow eval and started oral intake.
# Communication: HCP is Daughter [**Name (NI) **]
# Code: Full code
Medications on Admission:
tiotropium 1 cap daily
advair 500/50 one puff [**Hospital1 **]
albuterol inhaler 2 puff q4h prn
albuterol neb q4h prn
prednisone 10mg po daily
lorazepam 1mg q4h prn
citalopram 20mg po daily
oxygen 3L
pantoprazole 40mg po daily
Discharge Medications:
1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheezing
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
8. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
10. Docusate Sodium (Liquid) 100 mg PO BID
11. Senna 1 TAB PO BID:PRN Constipation
12. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
13. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN odynophagia
14. Heparin 5000 UNIT SC TID
15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
16. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
17. Diltiazem Extended-Release 360 mg PO DAILY
hold for SBP<100 or HR<60
18. PredniSONE 40 mg PO DAILY
19. Citalopram 20 mg PO DAILY
20. Vitamin D 1200 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
COPD exacerbation
Pneumonia strep
PEA arrest
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the hospital.
.
You were admitted to the hospital after having difficulty
breathing. You were intubated and put on a breathing machine for
a period of time. You were found to have a pneumonia and a
severe COPD exacerbation. Your admission was complicated by your
heart stopping and you underwent CPR and a cooling protocol. You
recovered and were taken off the breathing machine. You are now
being transferred to a rehab facility for further care.
.
Please follow the attatched medication list which will be
continued at rehab.
.
Please establish care with a pulmonologist once leaving rehab.
.
You should also receive pneumovax with your primary care
physician after discharge
Followup Instructions:
Follow with the rehab facility
ICD9 Codes: 5849, 2762, 2760, 4275, 2859 | [
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train_43333 | completed | 49d0aae0-33e5-4380-b4cf-af07ee3e3ec1 | Medical Text: Admission Date: [**2155-12-18**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80 year old
male with a history of Parkinson's disease contractures,
history of tracheostomies for inability to handle secretions,
history of urinary tract infection, aspiration pneumonia,
congestive heart failure and glaucoma presenting to the
MICU/SICU for evaluation for placement of [**Location (un) **] tube and
evaluation by interventional pulmonology.
The patient had a tracheostomy placed for greater than one
year. Starting in the fall he had problems that
tracheostomy, specifically problems with suctioning. The
patient apparently had difficulty in the initial placement of
the tracheostomy tube with a "actual long tube placed" and
the tube was apparently difficult to place. The patient was
unable to be suctioned in [**Month (only) 359**] and was sent to the
Operating Room after admittance for tracheostomy tube change.
It was successful. He went back to the nursing home and was
okay from that perspective until [**11-29**], when again he
could he could not be suctioned. He was taken to the
Operating Room for revision. Revision failed, however,
thoracic surgery reported a large area of necrotic tissue
with difficulty localizing the anterior wall of the trachea.
Because of that, endotracheal tube was placed on [**2155-12-4**] and the patient was placed on a T-piece at 40% FIO2.
The patient had fevers at that point at the outside hospital
and was treated for a pneumonia/bronchitis with Oxacillin and
Ceftazidime for 10 days. He had a neck computerized
tomography scan which showed "a large amount of granulation
tissue." Cardiothoracic Surgery and Otorhinolaryngology felt
they could not intervene. Based on this, the patient was
referred to the [**Hospital6 256**] for
further evaluation by Pulmonary Surgery. By report from the
outside hospital the patient had no positive micro-data and
was on no precautions.
PAST MEDICAL HISTORY:
1. Severe Parkinson's disease
2. History of tracheostomy because of inability to handle
secretions
3. History of urinary tract infections
4. History of aspiration pneumonias
5. History of decubitus ulcers
6. History of congestive heart failure
7. Glaucoma
8. Urinary retention
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Kayciel
2. Lasix 20 q.d.
3. Zantac 150 b.i.d.
4. Multivitamin one q.d.
5. Carbidopa
6. Levodopa 25/50 mg t.i.d.
7. Reglan 5 mg t.i.d.
8. Colace 100 q.d.
9. Pilocarpine 6% one drop both eyes, q.d.
10. Xalatan .005% one drop both eyes, q.h.s.
11. Jevity tube feeds 80 cc/hr and 200 cc free water boluses
b.i.d.
SOCIAL HISTORY: The patient is a retired minister.
FAMILY HISTORY: Not available.
PHYSICAL EXAMINATION: Vital signs on presentation - The
patient was afebrile with a pulse of 88, blood pressure
141/85 and saturation of 100% breathing at 22. Clinically,
generally speaking the patient was chronically ill-appearing
male, contracted. Head, eyes, ears, nose and throat,
normocephalic, atraumatic with pinpoint pupils bilaterally as
is his baseline. Dry mucous membranes. He has a
tracheostomy site that had a dry exudate. Heart, regular
rate and rhythm, no gallops, rubs or murmurs. Neck, right
internal jugular line that was clean, dry and intact, unclear
when the internal jugular line was placed. Lungs, decreased
breathsounds, right greater than left, coarse rhonchi
throughout. Abdomen, soft, gastrostomy tube in place, clean,
dry and intact, no erythema, decreased bowel sounds in th
abdomen. Extremities, no cyanosis, clubbing or edema.
Pulses 2+ dorsalis pedis and posterior tibial. Area of skin
breakdown on sacrum as well as tibia. Neurological, not
communicative. Follows simple commands, able to grip. 2+
deep tendon reflex bilaterally in upper and lower
extremities. Cranial nerves, unable to assess. The patient
with dysconjugate gaze.
LABORATORY DATA: Outside laboratory data - SMA on [**12-10**], sodium 144, potassium 4.3, chloride 108, bicarbonate 34,
BUN 23, creatinine 0.9 and glucose 199. Complete blood count
at outside laboratory, 10.5 white blood count, 31.4
hematocrit, 177 platelet count. Arterial blood gases at the
outside hospital 7.3, 8, 57, 76 on 40%. No other laboratory
data is available from the outside laboratory.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 24764**]
MEDQUIST36
D: [**2155-12-18**] 17:43
T: [**2155-12-18**] 18:50
JOB#: [**Job Number 37285**]
ICD9 Codes: 4280 | [
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train_42964 | completed | 330bea59-ceea-4f7f-b6b4-1b86d2a4ef27 | Medical Text: Admission Date: [**2132-7-14**] Discharge Date: [**2132-7-25**]
Date of Birth: [**2069-11-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Keflex / Latex
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
hypoxia, shortness of breath
Major Surgical or Invasive Procedure:
intubation
bronchoscopy and BAL
Arterial line
Double Lumen PICC
History of Present Illness:
This patient is a 62 year old female who complains of HYPOXIA.
Patient from rehab, tx from [**Hospital3 13313**] with Shortness
of breath (SOB) and hypoxia. She s/p right ankle surgery this
past week, on levaquin for pneumonia post op (started a week
ago, still on levoquin). She had a sudden worsening of
respiratory distress today with saturations in the 80s. Chest
x-ray at outside hospital shows infiltrates worse on the left
side. She is on Coumadin but INR only 1.7. Her outside doctor
he confirmed with her that she is DNR/DNI and currently refuses
intubation. 97% O2 saturations on non-RB. Given nebs X 3 en
route.
.
As per OMR note from Infectious disease (ID, OPAT), "she had
recent admission was for right foot hardware infection s/p
removal of external fixation device, found to have line-related
blood stream infection (Vancomycin resistant enterococcus - VRE,
CoNS), right foot osteomyelitis with VRE, ESBL Klebsiella, and
staph aureus (with hardware in place), urinary tract infection
(UTI) with ESBL klebsiella and possible PNA. Additionally,
patient has significant antibiotic allergies to penicillin (PCN)
and sulfa. PICC line was removed, subsequent cultures were
drawn. Recommended endocarditis eval bc of VRE, CoNS BSI.
Transthoracic echo (TTE) was negative for vegetations. For
treatment, ID recommended daptomycin for VRE blood stream
infection and daptomycin + meropenem for osteomyelitis; and
meropenem for UTI (ESBL klebsiella). Because the patient has
osteomyelitis with hardware in place, she requires indefinite
suppression, the VRE was sensitive to levofloxacin and will be
the [**Doctor Last Name 360**] for longterm oral suppression after pt completes 6-wk
course with daptomycin and meropenem. However, the meropenem was
stopped on [**7-6**] transiently and was re-instated on [**7-8**]."
.
In ED, initial vitals were: 96.7 94 124/76 24 97%
Non-Rebreather.
Exam was significant for b/l rhonchi no wheezing, no splinter,
rle in caste, neurovascular compromise, b/l edema noted. Labs
were significant for Hct of 25 baseline of 25-28, INR of 1.8.
Patient underwent Xray "multifocal PNA" per read. Patient was
given Vancomycin and meropenem. Patient was not seen by any
consults. Patient was admitted for multifocal PNA. Vitals prior
to transfer 97, 88, 134/72, 25, 95% NRB, 3 PIV.
.
On the floor, she appears to be comfortable.
.
Review of systems:
(+) Per HPI
Past Medical History:
DM c/b neuropathy
Charcot foot
chronic lower back pain,
spinal stenosis, s/p lumbar laminectomy/fusion 4 years ago
s/p I+D rt foot [**7-/2131**]
Hepatitis C
Depression
Hypertension
Obstructive Sleep Apnea on CPAP
Asthma
Social History:
-Retired nurse. Lives with parents.
-tobacco: quit smoking 7 months ago
-alcohol: none
-Drugs: none
Family History:
Diabetes
Physical Exam:
Admission Physical exam
Vitals: T: 97 BP:129/67 P:86 R: 18 O2: 95%
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical exam
T 98.0, HR 81, BP 150/70, RR 20, 97%RA
General: A&Ox3, NAD resting comfortably in bed smiling,
minimally hoarse voice
HEENT: Sclera anicteric, dry MM, oropharynx clear
Lungs: CTA b/l, no wheezes or rhonchi, good expansion, no use of
accessory muscles
CV: 2/6 systolic murmur, regular rhythm, S1S2, no rubs or
gallops
Abdomen: soft, ND, NT, +BS, no rebound, no guarding
Ext: no e/c/c, 2+ peripheral pulses, spint and ace bandage of
right foot up to midcalf. Sensation and movement intact in toes
of right foot.
Pertinent Results:
Labs at admission:
[**2132-7-14**] 03:00PM BLOOD WBC-7.0# RBC-3.02* Hgb-8.0* Hct-25.3*
MCV-81* MCH-26.6* MCHC-32.6 RDW-14.8 Plt Ct-341
[**2132-7-14**] 03:00PM BLOOD Neuts-77.5* Lymphs-14.5* Monos-4.5
Eos-3.2 Baso-0.5
[**2132-7-14**] 03:00PM BLOOD PT-19.4* PTT-48.8* INR(PT)-1.8*
[**2132-7-14**] 03:00PM BLOOD Glucose-165* UreaN-14 Creat-0.9 Na-139
K-3.8 Cl-101 HCO3-31 AnGap-11
[**2132-7-14**] 03:00PM BLOOD ALT-25 AST-29 AlkPhos-270* TotBili-0.4
[**2132-7-14**] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1691*
[**2132-7-14**] 03:00PM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
Micro:
[**2132-7-16**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-PRELIMINARY; LEGIONELLA CULTURE-PRELIMINARY;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; NOCARDIA
CULTURE-PRELIMINARY; ACID FAST SMEAR-PRELIMINARY; ACID FAST
CULTURE-PRELIMINARY INPATIENT
[**2132-7-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-16**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-16**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2132-7-14**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2132-7-14**] URINE URINE CULTURE-FINAL INPATIENT
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-7-14**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2132-7-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
Imaging:
CT chest [**7-15**]
INDICATION: 62-year-old woman with diabetes and diabetic
nephropathy and
hypoxia, to rule out pulmonary embolism.
TECHNIQUE: Contrast enhanced CT of thorax was performed using
the standard
department protocol to evaluate pulmonary embolism. Contiguous
axial images
at 5 mm and 2.5 mm slice thickness were reviewed concurrently
with coronal and
sagittal reformats. Comparison was made with limited available
sections from
a prior abdominal CT dated [**2132-6-24**].
FINDINGS:
PULMONARY ARTERY: The study is technically adequate for
evaluation of
pulmonary embolism. The main pulmonary artery proximal to
bifurcation
measures 3.9 cm in caliber and is enlarged suggestive of
pulmonary artery
hypertension. No filling defects seen within the main, lobar,
segmental and subsegmental branches to suggest pulmonary
embolism. No right heart strain or septal bulge.
LUNGS AND AIRWAYS: Central airways are patent till subsegmental
level.
Extensive multifocal pneumonic consolidation seen bilaterally
relatively
sparing the lower lobes basal segments. No areas of cavitation
seen within the
consolidation. Bilateral simple pleural effusions are minimal.
There is no
pneumothorax.
MEDIASTINUM: Multiple enlarged lymph nodes are seen in the
mediastinum and
the bilateral hilum, for example a precarinal lymph node
measures 1.9 x 1.4 cm
(4:14), right hilar node 13 x 10 mm (4:30) and a left hilar node
1.5 x 1.1 cm
(4:22). Heart is normal size without pericardial effusion.
ABDOMEN: The study is not tailored for evaluation of abdomen;
however,
limited views revealed partially imaged 4.0 x 5.4 cm lesion of
fluid
attenuation located in the lesser sac. This lesion is better
characterized on
the prior abdomen CT dated [**2130-6-25**] and kindly refer to
the
corresponding CT.
BONES: No bone lesion suspicious for malignancy or infection.
IMPRESSION:
1. There is no CT evidence of pulmonary embolism.
2. Extensive multifocal pneumonia involving both lungs.
3. Multiple enlarged mediastinal and hilar lymph nodes.
Findings were discussed with Dr. [**Last Name (STitle) **] over the phone on [**7-15**], [**2131**] at 5
p.m.
Echo [**7-15**]
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2132-6-25**], no
change.
EKG [**7-14**]
Sinus rhythm. No significant change compared to the tracing of
[**2132-6-29**]
CXR [**7-14**]
FINDINGS: Extensive opacification in the lungs bilaterally along
with
fullness of the hila and enlarged cardiomediastinal silhouette
concerning for
moderate-to-severe pulmonary edema. However slight asymmetry in
the opacities
could suggest infectious component. Left-sided PICC line is seen
with distal
tip not well seen, but possibly within the mid SVC. There is no
pleural
effusion or pneumothorax identified.
IMPRESSION:
1. Moderate-to-severe pulmonary edema worsened since the prior
studies.
2. PICC tip not well seen, possibly within the mid SVC.
Discharge labs:
[**2132-7-25**] 05:35AM BLOOD WBC-4.5 RBC-3.52* Hgb-9.4* Hct-27.5*
MCV-78* MCH-26.7* MCHC-34.2 RDW-16.6* Plt Ct-239
[**2132-7-19**] 04:02AM BLOOD Neuts-69.1 Bands-0 Lymphs-17.1* Monos-3.8
Eos-9.9* Baso-0.1
[**2132-7-25**] 05:35AM BLOOD Glucose-138* UreaN-19 Creat-1.1 Na-134
K-3.6 Cl-96 HCO3-27 AnGap-15
[**2132-7-23**] 04:12AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.1
[**2132-7-21**] 04:26AM BLOOD ANCA-NEGATIVE B
[**2132-7-23**] 04:28AM BLOOD Type-ART pO2-88 pCO2-45 pH-7.50*
calTCO2-36* Base XS-9
Brief Hospital Course:
Reason for admission: hypoxia and shortness of breath
62 yo female with diabetes, diabetic neuropathy and right sided
Charcot foot, status post (s/p) reconstruction and external
fixation, with recent right foot infection with hardware
infection/removal complicated by osteomyelitis, urinary tract
infection(UTI) and PICC line infection on daptomycin/meropenem,
and recent "PNA" at rehab on levofloxacin, presenting with
sudden onset of shortness of breath (SOB) with pulmonary
congestion and possible multifocal pneumonia (PNA).
.
Active Issues:
.
# Hypoxia: Had hypoxia during last admission, satting in 70s on
RA, then 84% on 6L NC. Albuterol, ipratropium nebs and
non-rebreather mask given then with O2 saturation recovered to
high 90s. She was diuresed and weaned off Lasix at discharge. On
review of her records, it seems that she had lasix as part of
her meds until [**5-12**], at which time she was not discharged on it.
Pt was continued on home meropenem, and started vancomycin
(concern for methicilin resistant staph aureus, MRSA, PNA) and
levofloxacin (concern for atypical PNA and VRE coverage). Her
daptomycin was held with concern for possible eosinophilic
pneumonia. Transthoracic echo (TTE) with bubble study was
obtained showing EF of 55%, otherwise normal. Patient was
intubated for bronchoscopy on [**7-16**] and remained intubated until
AM of [**7-22**] when she self-extubated on decreased sedation (for
planned extubation later that day). Bronchoscopy was done to
evaluate for eosinophilic pneumonia but there were minimal
eosinophils on BAL. She continued to improve clinically off
antibiotics (abx) for PNA given negative cultures (abx continued
for osteomyelitis). Patient transferred to the medicine floor
where her vital signs remained stable, she was breathing on room
air with lungs clear to auscultation bilaterally.
.
# Right foot/line/urinary tract infection: On [**2132-6-20**], she had
partial hardware/frame removal. Wound culture swab grew staph
aureus and klebsiella sensitive to gentamycin and meropenem.
Pin culture grew out klebsiella, staph aureus, and enterococcus
sensitive to daptomycin, gentamycin and bactrim. She also had
line infection- enterococcus and coagulase negative staph aureus
grew from PICC line culture on prior admission, which was pulled
on [**2132-6-23**]. Culture positive only from PICC line draw, not
peripheral draw or PICC tip. TTE was obtained on [**2132-6-25**], which
showed no evidence of endocarditis. She had evidence of a
klebsiella UTI, though this may be [**12-19**] colonization. Per ID
recommendation, she was started on [**Last Name (un) 2830**]/dapto, which pt started
[**2132-6-23**]. Podiatry recommended reimaging with xray prior to
discharge and planned to replace cast [**2132-7-17**]. On this admission,
patient was changed to Meropenem, Vancomycin, and Levofloxacin
given possibility of Dapto causing eosinophilic pneumonia.
Coverage was narrowed to [**Last Name (un) **] and Levo, at Infection disease
consult's suggestion. Podiatry was consulted who recommended a
new [**Hospital1 **]-valve, non-weight bearing cast for her right foot.
Patient remained afebrile with stable vital signs on the floor
and looked remarkably well. Plan is for her to follow up with
podiatry in 4 days to reassess weight bearing status. From an
infection stand point, she will need 4 additional weeks of IV
antibiotics ([**Last Name (un) 2830**] and levo).
.
#. Diminished hearing - Noted on admission, unclear etiology,
possibly secondary to medication toxicitiy, possibly lasix,
antibiotics also a consideration. Patient without current
complaints. Can consider audiology f/u as an outpatient.
.
#. Eosinophilia - unclear what etiology of this is, considered
allergic reaction to daptomycin, has since been discontinued.
Also consideration of latex allergy.
.
Chronic Issues:
.
# History of right upper quadrant pain: thought to be biliary
colic. Issue was not aggressively evaluated in the hospital. An
outpatient GI follow up appointment was made, which she can
consider or arrange an elective cholecystectomy in the future
should she choose to pursue that.
.
# Diabetes mellitus type II: Patient was on insulin sliding
scale during admission (using latex free insulin, Novolog) and
gabapentin was continued for neuropathic pain
.
# Hypertension: Blood pressure medications were held duing ICU
stay. Patient was given several doses of lasix for duiresis.
Blood pressure 150/70 on discharge. Can restart home
amlodipine.
.
# Low back pain - managed over admission with home fentanyl
patch, oxycodone prn. Patient additionally on a bowel regimen
and having BMs.
.
# Depression: outpatient regimen was continued - venlafaxine and
bupropion.
.
# Hypothyroid: home dose of levothyroxine was continued.
.
# Obstructive sleep apnea - on CPAP at home.
.
# Anxiety: Patient's home ativan was continued.
.
Transitional Issues:
Patient is returning to her previous rehabilitation facility,
[**Hospital 10478**] rehab, which is affiliated with her long term living
facility. The IV antbiotics can be given there. She will need
to be followed up with podiatry at [**Hospital1 18**] early next week.
Medications on Admission:
- aspirin 81 mg PO DAILY.
- polysaccharide iron complex 150 mg PO DAILY.
- amlodipine 10 mg PO DAILY.
- lorazepam 0.5 mg PO BID (2 times a day)
- levothyroxine 200 mcg PO DAILY
- oxycodone 15 mg Tablet PO Q4H PRN pain (held)
- fentanyl 50 mcg/hr Patch every 72 hours
- simvastatin 20 mg PO QHS
- gabapentin 300 mg PO QAM
- gabapentin 600 mg PO QPM
- venlafaxine 225 mg PO DAILY.
- Wellbutrin XL 300 mg ER 24 hr PO once a day.
- trazodone 500 mg Tablet PO HS PRN insomnia.
- senna 8.6 mg Tablet PO DAILY
- docusate sodium 100 mg PO once a day PRN constipation.
- bisacodyl 10 mg PR DAILY PRN constipation.
- acetaminophen 650 mg PO once a day as needed for pain.
- Milk of Magnesia PO once a day as needed for constipation.
- Fleet Enema 19-7 gram/118 mL once a day PRN constipation
- Novolin 70/30 suspension 25 units Subcutaneous qAM.
- Novolin 70/30 Suspension 20 units Subcutaneous qPM.
- insulin lispro as directed Subcutaneous as directed.
- meropenem 1 gram IV Q8H
- daptomycin 800 mg IV Q24H
- Vitamin D3 50,000 UI po qWEEK
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polysaccharide iron complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
3. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime.
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. trazodone 100 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime) as needed for insomnia.
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO PRN (as needed) as needed for constipation.
13. bupropion HCl 300 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Three (3)
Capsule, Ext Release 24 hr PO DAILY (Daily).
16. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO every [**2-20**]
hours as needed for pain.
17. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed.
19. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
20. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: One (1) 25
units Subcutaneous once a day.
21. Novolin 70/30 100 unit/mL (70-30) Suspension Sig: One (1) 20
units Subcutaneous at bedtime.
22. meropenem 1 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 4 weeks: last dose on [**2132-8-27**].
23. Outpatient Lab Work
Please check CBC with differential, BMP, LFT, CK, ESR, CRP
weekly starting on [**2132-7-28**]. Please fax results to the
Infectious Disease RN at ([**Telephone/Fax (1) 4591**]. Call ([**Telephone/Fax (1) 21403**] with
any questions.
24. levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous once a day for 4 weeks: last dose on
[**2132-8-27**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 13316**]Healthcare Center - [**Hospital1 10478**]
Discharge Diagnosis:
Primary Diagnosis:
Multifocal Pneumonia
Pulmonary congestion
Right Foot osteomyelitis with ESBL kelbsiella, MRSA, VRE
Secondary diagnosis:
DM c/b neuropathy
Charcot foot
chronic lower back pain,
spinal stenosis, s/p lumbar laminectomy/fusion 4 years ago
s/p I+D rt foot [**7-/2131**]
Hep C
depression
HTN
OSA on CPAP
asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 87206**],
You were admitted to the hospital because you were having
shortness of breath and difficulty getting oxygen into your
blood. You had several chest xrays and a CT scan of your chest
that showed a multifocal pneumonia as well as fluid in your
lungs, both of which were causing you to have difficulty
breathing. Because of this, if was felt that you should be
intubated. You were given lasix (a duiretic) to get the fluid
out of your lungs as well as antibiotics to treat the pneumonia
in your lungs in addition to the infection in your foot and in
your blood. You improved clinically, no longer needed to be
intubated and are now stable for discharge to rehab with
intravenous antibiotics to treat your infections, and follow up
with podiatry for your foot.
Please continue your home medications as prescribed.
The follwing changes were made to your home medications:
- STOP taking Daptomycin.
- CONTINUE to take the Meropenem IV 3 times per day until
[**2132-8-27**].
- START Levofloxacin IV once per day for until [**2132-8-27**].
- you will need to have weekly labs checked, with results faxed
to the infectious disease office
Dear Ms. [**Known lastname 87206**],
You were admitted to the hospital because you were having
shortness of breath and difficulty getting oxygen into your
blood. You had several chest xrays and a CT scan of your chest
that showed a multifocal pneumonia as well as fluid in your
lungs, both of which were causing you to have difficulty
breathing. Because of this, if was felt that you should be
intubated. You were given lasix (a duiretic) to get the fluid
out of your lungs as well as antibiotics to treat the pneumonia
in your lungs in addition to the infection in your foot and in
your blood. You improved clinically, no longer needed to be
intubated and are now stable for discharge to rehab with
intravenous antibiotics to treat your infections, and follow up
with podiatry for your foot.
Please continue your home medications as prescribed.
The follwing changes were made to your home medications:
- STOP taking Daptomycin.
- CONTINUE to take the Meropenem IV 3 times per day until
[**2132-8-27**].
- START Levofloxacin IV once per day for until [**2132-8-27**].
- you will need to have weekly labs checked, with results faxed
to the infectious disease office
Followup Instructions:
Department: PODIATRY
When: MONDAY [**2132-7-28**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2132-7-29**] at 1:30 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2132-8-11**] at 10:10 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 486, 4280, 2449, 311, 4019 | [
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train_48118 | completed | a78761f6-c203-47b2-a4f4-aefe56c72d5c | Medical Text: Admission Date: [**2113-11-11**] Discharge Date: [**2113-11-19**]
Date of Birth: [**2078-6-22**] Sex: M
Service: 1
HISTORY OF PRESENT ILLNESS: The patient is a 35 year old
male with mental retardation who developed progressive
shortness of breath starting approximately one week prior to
admission associated with increasing fatigue. On the day of
admission, the patient reported shortness of breath at rest.
The patient denied any fevers, chills, headache, stiff neck,
lightheadedness, changes in vision, chest pain, palpitations,
back pain, nausea, vomiting, diarrhea, dysuria, bright red
blood per rectum, melena or change in stool or urine color.
In the Emergency Room, the patient had a temperature of 95.3
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Initial chest x-ray was read as
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2113-12-15**] 12:50
T: [**2113-12-15**] 15:03
JOB#: [**Job Number **]
ICD9 Codes: 486, 4254, 4280 | [
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train_48708 | completed | 16babc95-5969-4e8a-abf6-2f53d5e09901 | Age: 20
Gender: Female
Blood Type: A+
Medical Condition: Cancer
Date of Admission: 2021-12-28
Doctor: Suzanne Thomas
Hospital: Powell Robinson and Valdez,
Insurance Provider: Cigna
Billing Amount: 45820.46272159459
Room Number: 277
Admission Type: Emergency
Discharge Date: 2022-01-07
Medication: Paracetamol
Test Results: Inconclusive | [
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train_48751 | completed | 6fa2e93d-c3f0-40be-bc38-4abfeb810dc1 | Age: 30
Gender: Male
Blood Type: AB-
Medical Condition: Hypertension
Date of Admission: 2024-04-05
Doctor: Vicki Nguyen
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Insurance Provider: Medicare
Billing Amount: 30590.54180634067
Room Number: 456
Admission Type: Emergency
Discharge Date: 2024-04-22
Medication: Paracetamol
Test Results: Inconclusive | [
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train_48774 | completed | 17f4e252-4e96-440a-9dfa-f81714ee1209 | Age: 27
Gender: Male
Blood Type: AB-
Medical Condition: Diabetes
Date of Admission: 2021-09-16
Doctor: Raven Wong
Hospital: Sons and Schaefer
Insurance Provider: Aetna
Billing Amount: 45353.990777385414
Room Number: 263
Admission Type: Urgent
Discharge Date: 2021-10-14
Medication: Penicillin
Test Results: Abnormal | [
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train_48777 | completed | c7e2b8cb-2960-4c7c-92a0-60035d3c46a9 | Age: 22
Gender: Female
Blood Type: A-
Medical Condition: Arthritis
Date of Admission: 2023-10-11
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Insurance Provider: Blue Cross
Billing Amount: 42696.52116389919
Room Number: 102
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Medication: Penicillin
Test Results: Normal | [
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train_48799 | completed | a1c6cca3-8bc1-4971-b8b5-0cacf6f38e42 | Age: 53
Gender: Male
Blood Type: B-
Medical Condition: Cancer
Date of Admission: 2022-09-14
Doctor: Stephanie Clements
Hospital: Parsons, Hartman Martinez and
Insurance Provider: Blue Cross
Billing Amount: 30437.001787641067
Room Number: 208
Admission Type: Elective
Discharge Date: 2022-09-18
Medication: Aspirin
Test Results: Normal | [
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train_48809 | completed | d1ba5b5a-78e8-4549-a468-475f3397b2cf | Age: 52
Gender: Male
Blood Type: AB-
Medical Condition: Hypertension
Date of Admission: 2021-05-14
Doctor: Christopher Butler
Hospital: Stout-Brown
Insurance Provider: Cigna
Billing Amount: 37734.74218038699
Room Number: 251
Admission Type: Elective
Discharge Date: 2021-06-06
Medication: Penicillin
Test Results: Abnormal | [
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train_48842 | completed | e684e543-3ad4-4694-b33a-d2dc3ff5cc9b | Age: 20
Gender: Male
Blood Type: O-
Medical Condition: Diabetes
Date of Admission: 2024-01-05
Doctor: Victoria Gonzales
Hospital: and Marquez Silva Smith,
Insurance Provider: Medicare
Billing Amount: 48995.98059165719
Room Number: 406
Admission Type: Elective
Discharge Date: 2024-02-04
Medication: Lipitor
Test Results: Normal | [
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train_48860 | completed | 91cded22-65c5-48bb-9aeb-c6855a14f9f7 | Age: 29
Gender: Male
Blood Type: O-
Medical Condition: Asthma
Date of Admission: 2020-02-27
Doctor: Erica Mccormick
Hospital: Donaldson-Frey
Insurance Provider: Medicare
Billing Amount: 41939.11993669633
Room Number: 453
Admission Type: Elective
Discharge Date: 2020-03-26
Medication: Ibuprofen
Test Results: Normal | [
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train_48882 | completed | eb0a46b0-33c2-45da-863d-28294ee7b83a | Age: 81
Gender: Female
Blood Type: B-
Medical Condition: Diabetes
Date of Admission: 2020-05-08
Doctor: Taylor Baldwin
Hospital: LLC Lewis
Insurance Provider: Aetna
Billing Amount: 17968.495987590006
Room Number: 285
Admission Type: Emergency
Discharge Date: 2020-05-28
Medication: Lipitor
Test Results: Inconclusive | [
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train_23780 | completed | 2d96b8ae-3ada-484c-8196-64cf76f8c63d | Medical Text: Admission Date: [**2152-10-2**] Discharge Date: [**2152-11-8**]
Date of Birth: [**2094-3-1**] Sex: F
Service: VSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Chest Pain with Radiation to the Back
Major Surgical or Invasive Procedure:
[**2152-10-3**] Central Venous Line Placement
[**2152-10-5**] Repair of aortic dissection with 32 mm Dacron graft and
partial cardiopulmonary bypass
[**2152-10-6**] Fiberoptic bronchoscopy
[**2152-10-10**] Bronchoscopy with BAL and therapeutic aspiration of
retained secretions.
[**2152-10-25**] Percutaneous tracheostomy tube placement.
History of Present Illness:
This is a 58 year old female with a past medical history
significant for HTN, asthma, obesity who is a long time smoker.
She started experienceing chest pain at approximately 10:20 am
on the date of admission. The pain was described as tearing,
constant substernal pain with radiation to head and the back.
She also reported SOB. She therefore presented to an OSH and
received IV lopressor and Toradol which improved the pain. She
underwent a CT scan which showed a type B aortic dissection
starting distal to the subclavian artery and extending to the
right iliac. The takeoff of the celiac/ SMA/ and bilateral renal
vessels came off the true lumen, however the [**Female First Name (un) 899**] came off of the
true lumen. She present to the [**Hospital1 18**] for further evaluation and
treatment.
Past Medical History:
1) Poorly controlled hypertension
2) Ashtma
3) Obesity
Social History:
Active smoker; 15 pk years. No Etoh, No Drugs.
Family History:
Negative for aortic dissection; negative for CAD.
Physical Exam:
VS: P 60, BP 96/60 R-20 98%4L
Gem: A+Ox3
HEENT: PERRLA EOMI
Neck: No Carotid Bruits
Heart: Distant, RRR w/o M
Chest: Bilateral Rhonchi, wheezes l>r
ABD: SNTND. No rebound
Vasc: Radial Femoral DP PT
R A-Line 2+ 2+ 2+
L 2+ 2+ 2+ 1+
Pertinent Results:
[**2152-10-2**] 11:42PM HCT-30.5*
[**2152-10-2**] 07:47PM TYPE-ART PO2-71* PCO2-40 PH-7.32* TOTAL
CO2-22 BASE XS--5
[**2152-10-2**] 07:47PM LACTATE-1.5
[**2152-10-2**] 07:47PM O2 SAT-93
[**2152-10-2**] 07:47PM freeCa-1.18
[**2152-10-2**] 07:11PM POTASSIUM-4.2
[**2152-10-2**] 07:11PM WBC-10.6 RBC-4.06* HGB-11.2* HCT-32.3*
MCV-80* MCH-27.6 MCHC-34.7 RDW-14.8
[**2152-10-2**] 07:11PM CALCIUM-8.6 PHOSPHATE-4.9* MAGNESIUM-2.0
[**2152-10-2**] 07:11PM PLT COUNT-213
[**2152-10-2**] 03:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2152-10-2**] 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2152-10-2**] 03:20PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2152-10-2**] 02:40PM GLUCOSE-118* UREA N-15 CREAT-0.8 SODIUM-143
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-14
[**2152-10-2**] 02:40PM WBC-12.1* RBC-4.34 HGB-11.8* HCT-33.6*
MCV-77* MCH-27.3 MCHC-35.3* RDW-14.7
[**2152-10-2**] 02:40PM NEUTS-84.1* LYMPHS-12.7* MONOS-2.7 EOS-0.2
BASOS-0.2
[**2152-10-2**] 02:40PM MICROCYT-1+
[**2152-10-2**] 02:40PM PLT COUNT-217
[**2152-10-2**] 02:40PM PT-13.4 PTT-22.9 INR(PT)-1.1
Brief Hospital Course:
The patient was admitted to the surgical intensive care unit for
tight blood pressure control. The patient had no visceral or
lower extremity ischemia, however, over the last two days the
aneurysm has been seen to be enlarging on CT scan and there was
some suggestion of blood in the left chest suggesting contained
rupture. For that reason, she was taken to the operating room
on [**2152-10-5**] at which time she underwent a repair of the aortic
dissection with 32 mm Dacron graft and partial cardiopulmonary
bypass. Postoperatively admitted to the SICU and remained in
critical condition requiring pressor support. She was seen in
consult with neurology and pulmonary medicine. She was noted to
develop a right sided parietal hemmorrhage on [**2152-10-5**], and then
developed a new left frontal lobe ischemic infarct which was
visualized in CT scan on [**2152-10-10**]. Additionally, she was found
to have anterior mediastinal and left retroperitoneal hematoma
(10x9cm) on [**10-17**]. Over the ensuing two weeks, she gradually
improved, but it became apparent given her respiratory failure
that she would benefit from a tracheostomy. She therefore
underwent placement of a percutaneous trach on [**2152-10-25**]. Over
the following two weeks she weened to trach mask trials and
eventually to trach collar. She was deemed to be appropriate to
transfer to rehab on [**2152-11-7**] where she will continue her
recuperation.
Medications on Admission:
HCTZ
Lisinopril
Discharge Medications:
Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **]
Insulin SC (per Insulin Flowsheet)
Breakfast/ Bedtime NPH 10 Units
Insulin SC Sliding Scale Q6H
Regular
Glucose Insulin Dose
0-60 mg/dL [**2-11**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
> 240 mg/dL Notify M.D.
Insulin NPH 10u sc qam and qhs
Potassium Chloride 40 mEq NG [**Hospital1 **]; Hold for K > 4
Nystatin Oral Suspension 5 ml PO prn
Lorazepam 1 mg PO BID
Albuterol-Ipratropium [**2-11**] PUFF IH Q6H:PRN
Heparin 5000 UNIT SC TID
Amiodarone HCl 400 mg PO QD
Furosemide 40 mg IV BID
Albuterol Neb Soln 1 NEB IH Q6H
Miconazole Powder 2% 1 Appl TP TID:PRN
Metoprolol 50 mg PO BID
Bisacodyl 10 mg PR HS:PRN
Milk of Magnesia 30 ml PO Q6H:PRN
Amlodipine 10 mg PO QD
Oxycodone-Acetaminophen [**6-19**] ml PO
Lansoprazole Oral Suspension 30 mg NG
Aspirin 325 mg PO QD
Artificial Tears 1-2 DROP OU PRN
Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Type B aortic dissection starting distal to the subclavian
artery and extending to the right iliac
Type A intramural hematoma involving the entire ascending aorta
from the aortic valve level with penetreting ulcer in left
lateral aspect of the distal ascending aorta (proximal to the
brachicephalic artery).
Right Parietal lobe hemorrhage ([**2152-10-5**])
Left Frontal Lobe Ischemic Infarct ([**2152-10-10**])
HTN
Asthma
Respiratory Failure
Retained Secretions
Retroperitoneal hematoma
Hypokalemia
Atrial Fibrilation
Blood Loss Anemia
Discharge Condition:
Good
Discharge Instructions:
The patient should return to the hospital for evaluation if she
develops fever, chills, or redness around the wound sites.
Followup Instructions:
The patient should follow-up with Drs. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) **] [**Last Name (Prefixes) **], M.D.
ICD9 Codes: 2851, 5185 | [
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train_24070 | completed | f09850b7-8410-4710-b6d8-6fb291bd499b | Medical Text: Admission Date: [**2183-3-12**] Discharge Date: [**2183-3-15**]
Date of Birth: [**2121-9-5**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is a 61- year- old female
with a history of right ICA stenosis 75-80% and left ICA
stenosis 65-70% stenosis and a [**Doctor Last Name **] aneurysm 3.5 mm from the
anterior communicating artery. This patient is admitted for
coiling of the ACOM aneurysm.
PAST MEDICAL HISTORY:
1. Hypertension.
2. CAD with CABG in [**2179**].
3. Dyspnea.
4. COPD.
5. Reflux.
6. Patient also has a history of schizophrenia.
MEDICATIONS:
1. Haldol 3 mg q.8 a.m., 2 mg q.2 p.m., and 3 mg q.8 p.m.
2. Cogentin 1 mg p.o. b.i.d.
3. Atenolol 100 q.d.
4. Lipitor 20 q.d.
5. Zestril 40 q.d.
6. Cartia XT 180 q.d.
7. Aspirin 325 q.d.
8. Serax 15 b.i.d.
9. Zantac 150 b.i.d.
10. Plavix 75 mg q.d.
11. Trazodone 200 q.h.s.
PAST SURGICAL HISTORY:
1. CABG x3 in [**2179**].
2. Hysterectomy.
3. Appendectomy.
PHYSICAL EXAM: In general, the patient was in no acute
distress. Mental status: Pleasant, cooperative, attentive.
Cardiac: S1, S2 slow rate, 3+ carotid bruit on the right.
Chest was clear to auscultation with fine crackles at the
bases, clear with cough. Abdomen is soft and nontender.
Extremities: No edema, 1+ right radial pulse, left radial
pulse. Dopplerable DP pulses in the lower extremities.
Pupils are equal, round, and reactive to light. Face
symmetric. Right lip decreases with smile. Tongue midline.
Patient was admitted status post a coil embolization of an
ACOM aneurysm without interprocedure complications. She was
monitored in the recovery room overnight. Her sheaths were
removed. There was no hematoma to her right groin. Her
pedal pulses remained intact. She was awake, alert, and
oriented times three. EOMs full. Visual fields were full to
confrontation. Her smile was symmetric. Her extremities
were full strength and equally bilaterally.
She was transferred to the regular floor on postoperative day
one. Her Foley was D/C'd. She was voiding spontaneously,
tolerating a regular diet. Was assessed by Physical Therapy
and found to be safe for discharge home. She was discharged
on [**2183-3-15**] in stable condition with followup with Dr.
[**Last Name (STitle) 1132**] in two weeks.
MEDICATIONS ON DISCHARGE:
1. Haldol 2 mg p.o. q2 p.m., Haldol 3 mg p.o. b.i.d.
2. Trazodone 200 mg p.o. q.h.s.
3. Zantac 150 mg p.o. b.i.d.
4. Lisinopril 40 mg p.o. q.d.
5. Atorvastatin 20 mg p.o. q.d.
6. Atenolol 100 mg p.o. q.d.
7. Colace 100 mg p.o. b.i.d.
8. Aspirin 325 p.o. q.d.
9. Plavix 75 mg p.o. q.d.
10. Percocet 1-2 tablets p.o. q.4h. prn.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
FOLLOW-UP INSTRUCTIONS: Follow up with Dr. [**Last Name (STitle) 1132**] in two
weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2183-3-14**] 16:02
T: [**2183-3-18**] 05:17
JOB#: [**Job Number 35426**]
ICD9 Codes: 496, 4019 | [
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train_22560 | completed | 258f7608-cabe-4459-935a-93795d3b0eee | Medical Text: Admission Date: [**2176-12-29**] Discharge Date: [**2177-1-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fatigue, weakness, respiratory distress
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. [**Known lastname 100345**] is an 81 yo male with a h/o facioscapulohumeral
muscular dystrophy, IDDM, "TIAS", neuropathy, and OSA who
presented to the ED with a week of increasing fatigue. In the
ED, temp was 102. SBP 80s increased to 120s w/500cc NS. Ceftaz
and vancomycin were given and an IJ was placed for possible
sepsis. On preparation for transfer, he was felt to be in resp
compromise so he was intubated.
Past Medical History:
1. CAD with evidence of 3vessel disease on cardiac cath [**9-3**].
2. CHF with EF of 55%
3. CRI (b/l 1.7)
4. OSA
5. HTN
6. Diabetes
Social History:
Lives with wife in [**Name (NI) **], MA. Has visiting nurse
during days. Son and daughter live locally and are quite
involved
in their father s care. Tobacco: 90 pack-yr history. Quit 7 yrs
ago. Denies current EtOH.
Family History:
per son, nobody else in family with symptoms of
or diagnosis of FSH musc dystrophy. No other family h/o
neurologic disease. Daughter died of pancreatic cancer last year
Physical Exam:
98.7 113/63 63 14 100%on AC650 X 14 w/PEEP5 and FIO2 100%
Intubated, sedated on propofol being transitioned to
fentanyl/versed
MMM
Poor air movement
Nl S1/S2
Soft, nt, nd, +BS
WWP X 4
Pertinent Results:
CXR: Poor quality AP film w/RLL PNA and appropriately positioned
ETT
[**2176-12-29**] 12:00AM PT-13.5* PTT-29.6 INR(PT)-1.2*
[**2176-12-29**] 12:00AM PLT COUNT-184
[**2176-12-29**] 12:00AM WBC-18.1*# RBC-4.95 HGB-14.8 HCT-43.5 MCV-88
MCH-30.0 MCHC-34.1 RDW-20.5*
[**2176-12-29**] 12:00AM CK-MB-9 cTropnT-0.46*
[**2176-12-29**] 12:12AM LACTATE-2.0
[**2176-12-29**] 03:10AM LACTATE-1.2
[**2176-12-29**] 10:28AM LACTATE-1.0
Brief Hospital Course:
Resp failure most likely secondary to sepsis in setting of PNA
on CXR- unlikely to be related to fluids since patient is
presenting with picture of sepsis. He was hypotensive, low UOP,
elevated WBC, febrile in the ED and found to have a RLL PNA on
CXR. Also has underlying COPD. extubated [**2177-1-5**], doing well.
Note that the patient started at a baseline of multiple
comorbidities so it is possible that only a small insult was
necessary to exacerbate his FTT. SV02 was 78
- sputum culture grew: pseudomonas([**Last Name (un) 36**] to ceftaz) and strep
pneum([**Last Name (un) 36**] to pcn)
- legionella negative
- on levaquin 750 po q daily (started [**2177-1-3**]) requiring 14 day
course ending on [**2177-1-17**] (switched to q 48 hours for CrCl of 34)
- pt was OOB to chair with chest PT doing well
- blood culture negative
- U/A negative, urine culture negative
.
Cardiac:
-Hypertension:
-- metoprolol 25 [**Hospital1 **]
-CAD: No evidence active ischemia on EKG.
-- troponin 0.46, 0.38, 0.27, 0.26
-- on ASA and atorvastatin
.
Eye surgery: opthomalogy consulted and evaluated patient and
recommended erythromycin ointment to eye
- spoke with optho on phone, stitch stays in place for > 6 weeks
- continue to monitor for signs of infection
.
COPD- continue nebs/ inhalers on vent. steroids stopped [**1-1**]
.
DM- Tight control while in ICU. on ISS. would continue this in
rehab.
.
Renal failure: creatinine had gone up in setting of lasix and
diuresis. (1.6 appears to be baseline.)
- discharge home with 40 po lasix q daily
.
FEN- on TF. able to tolerate thick nectar, soft po intake for
meds with assistance. NGT left in place.
.
Psych meds:
- continued on celexa as well as home dose ritalin and zyprexa
for agitation and anxiety
.
Prophylaxis: PPI, pneumoboots, heparin SQ
.
Code- DNR/DNI
Medications on Admission:
Accupril five milligrams daily
Lipitor ten milligrams daily
Neurontin 300 mg four times a day
Ritalin-SR
Celexa
Zyprexa
Provigil
Valtrex
Spiriva
Advair.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Disp:*30 syringes* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic HS (at bedtime).
8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4
times a day).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed.
14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
16. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO q 48
hours for 5 days.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Morphine 2 mg/mL Syringe Sig: [**12-3**] Injection Q2H (every 2
hours) as needed for pain/ anxiety.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
RLL pneumonia requiring intubation and antibiotic therapy
Discharge Condition:
stable and improving
Discharge Instructions:
You were hospitalized for a recent pneumonia requiring
intubation and ICU level care for 2 weeks. You are improving
each day and should continue on the medications prescribed
during your hospitalization.
You will be prescribed an antibiotic, Levaquin which you should
continue for 7 more days. You were also started on metoprolol
during your hospitalization. Lastly, your steroids were stopped.
If you should develop any fever, chills, nausea, vomiting,
respiratory distress, cough, chest pain or shortness of breath
you should call the facility physician or return to the ED.
Followup Instructions:
Follow up with the rehab facility PCP frequently to ensure that
your health continues to improve.
Monitor creatinine and electrolytes while on lasix
ICD9 Codes: 0389, 4280, 5856, 496, 5119, 5849, 4271 | [
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"624788f6-482b-4389-a2d5-db8fd9925c88"
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train_23659 | completed | e72b228f-53c9-4c3f-9e86-ed030a543e5e | Medical Text: Admission Date: [**2159-1-17**] Discharge Date: [**2132-3-17**]
Service:
ADDENDUM: The patient was seen by PT, found to be stable,
independent, at baseline strength. The patient was
discharged to home.
FOLLOW-UP: Same.
DR [**First Name8 (NamePattern2) 125**] [**Last Name (NamePattern1) **] 14.118
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2158-1-19**] 12:51
T: [**2159-1-19**] 13:13
JOB#: [**Job Number 46957**]
ICD9 Codes: 4280 | [
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train_22815 | completed | bc303ccc-a307-4dbc-b5a3-12c54fa5a994 | Medical Text: Admission Date: [**2142-9-14**] Discharge Date: [**2142-9-21**]
Service:
ADDENDUM: The patient was admitted on [**2142-9-14**] for a
preop for coronary artery bypass graft, however, had
myocardial infarction while in house and that was medically
managed and the patient was taken by Dr. [**Last Name (STitle) 70**] to the
Operating Room on [**9-16**] not 19, [**2141**]. He underwent
coronary artery bypass graft times two.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2142-9-21**] 07:45
T: [**2142-9-21**] 09:14
JOB#: [**Job Number 35801**]
ICD9 Codes: 9971, 4019, 2720, 412 | [
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train_20645 | completed | 27b681e8-0a36-4a93-97d6-c37cad040cca | Medical Text: Admission Date: [**2150-2-25**] Discharge Date: [**2150-3-14**]
Date of Birth: [**2085-5-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2150-2-25**]: Left sided craniotomy for subdural evacuation
History of Present Illness:
64 y/o M with CAD s/p CABG x 2 and ruptured chordae tendinae s/p
mechanical mitral valve placement in [**1-11**] admitted to the
neurosurgical service on [**2-25**] for emergent evacuation of left
subdural hematoma (surgery on [**2-25**]) after falling and hitting
his head on the ice two days prior. Anticoagulation was reversed
with FFP and vitamin K. He did well postoperatively and a
heparin bridge was begun on [**3-2**], followed by the addition of
coumadin on [**3-5**]. His INR (1.7) has yet to become therapeutic
(2.5-3.5).
Past Medical History:
[**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery
Social History:
Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years.
Family History:
Mother had CAD and colon CA in her mid 70's. Father had COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM
O: Afebrile, stable
Gen: WD/WN, appears in pain.
HEENT: normocephalic, atraumatic.
Pupils: PERRL EOMs: intact, with lateral nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,with lens
implant; 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with
nystagmus in the lateral gaze.
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 [**6-9**] throughout. No pronator drift
Sensation: Intact to light touch
On Discharge:
AOx3, bilateral surgical pupils, full strength and power
throughout upper and lower extremities.
Pertinent Results:
[**2150-2-25**] 08:30AM BLOOD WBC-14.2* RBC-3.70* Hgb-11.8*# Hct-32.7*#
MCV-88 MCH-31.9 MCHC-36.1* RDW-13.8 Plt Ct-217
[**2150-2-25**] 11:47AM BLOOD WBC-12.7* RBC-3.27* Hgb-10.5* Hct-28.5*
MCV-87 MCH-32.2* MCHC-36.9* RDW-14.5 Plt Ct-229
[**2150-2-26**] 01:43AM BLOOD WBC-21.2*# RBC-3.16* Hgb-10.1* Hct-28.0*
MCV-89 MCH-32.0 MCHC-36.1* RDW-14.4 Plt Ct-248
[**2150-2-27**] 05:33AM BLOOD WBC-16.9* RBC-2.79* Hgb-8.7* Hct-24.8*
MCV-89 MCH-31.3 MCHC-35.1* RDW-14.5 Plt Ct-183
[**2150-2-28**] 07:30PM BLOOD WBC-11.5* RBC-2.78* Hgb-9.0* Hct-25.2*
MCV-91 MCH-32.2* MCHC-35.5* RDW-14.5 Plt Ct-252
[**2150-3-1**] 06:50AM BLOOD WBC-12.0* RBC-2.84* Hgb-9.2* Hct-25.6*
MCV-90 MCH-32.4* MCHC-35.8* RDW-14.5 Plt Ct-263
[**2150-3-2**] 05:45AM BLOOD WBC-13.2* RBC-2.95* Hgb-9.4* Hct-26.4*
MCV-89 MCH-31.9 MCHC-35.7* RDW-14.5 Plt Ct-307
[**2150-3-3**] 05:33AM BLOOD WBC-10.9 RBC-3.15* Hgb-9.9* Hct-28.0*
MCV-89 MCH-31.4 MCHC-35.3* RDW-14.8 Plt Ct-328
[**2150-3-5**] 05:40AM BLOOD WBC-12.4* RBC-3.04* Hgb-9.7* Hct-27.5*
MCV-91 MCH-31.9 MCHC-35.2* RDW-14.7 Plt Ct-382
[**2150-3-7**] 07:45AM BLOOD WBC-11.6* RBC-3.21* Hgb-9.7* Hct-29.3*
MCV-91 MCH-30.3 MCHC-33.3 RDW-14.6 Plt Ct-426
[**2150-3-8**] 07:56AM BLOOD WBC-12.5* RBC-3.33* Hgb-10.4* Hct-30.2*
MCV-91 MCH-31.2 MCHC-34.4 RDW-14.4 Plt Ct-473*
[**2150-3-10**] 05:55AM BLOOD WBC-10.9 RBC-3.22* Hgb-9.9* Hct-29.0*
MCV-90 MCH-30.9 MCHC-34.2 RDW-14.4 Plt Ct-461*
[**2150-3-12**] 07:50AM BLOOD WBC-9.9 RBC-3.42* Hgb-10.7* Hct-31.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-14.2 Plt Ct-505*
[**2150-3-13**] 09:05AM BLOOD WBC-9.2 RBC-3.55* Hgb-10.8* Hct-32.0*
MCV-90 MCH-30.4 MCHC-33.7 RDW-14.2 Plt Ct-508*
[**2150-3-14**] 08:00AM BLOOD WBC-9.8 RBC-3.59* Hgb-10.7* Hct-32.6*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.3 Plt Ct-494*
[**2150-2-25**] 06:42AM BLOOD PT-23.8* PTT-30.2 INR(PT)-2.3*
[**2150-2-25**] 08:30AM BLOOD PT-21.1* PTT-28.1 INR(PT)-2.0*
[**2150-2-25**] 11:47AM BLOOD PT-18.6* PTT-24.1 INR(PT)-1.7*
[**2150-2-26**] 01:43AM BLOOD PT-14.2* PTT-21.2* INR(PT)-1.2*
[**2150-3-5**] 05:40AM BLOOD PT-13.3 PTT-38.4* INR(PT)-1.1
[**2150-3-5**] 07:35PM BLOOD PT-14.6* PTT-60.6* INR(PT)-1.3*
[**2150-3-8**] 10:10PM BLOOD PT-15.9* PTT-96.4* INR(PT)-1.4*
[**2150-3-10**] 03:15PM BLOOD PT-16.7* PTT-56.2* INR(PT)-1.5*
[**2150-3-11**] 09:13PM BLOOD PT-19.0* PTT-72.0* INR(PT)-1.8*
[**2150-3-12**] 07:50AM BLOOD PT-21.4* PTT-95.8* INR(PT)-2.0*
[**2150-3-13**] 12:55AM BLOOD PT-22.9* PTT-120.6* INR(PT)-2.2*
[**2150-3-13**] 09:05AM BLOOD PT-23.3* PTT-75.0* INR(PT)-2.3*
[**2150-3-13**] 04:56PM BLOOD PT-22.0* PTT-53.2* INR(PT)-2.1*
[**2150-3-14**] 02:43AM BLOOD PT-22.9* PTT-69.7* INR(PT)-2.2*
[**2150-3-14**] 08:00AM BLOOD PT-24.9* PTT-97.4* INR(PT)-2.4*
[**2150-3-14**] 10:00AM BLOOD PT-25.1* PTT-92.9* INR(PT)-2.5*
[**2150-2-25**] 08:30AM BLOOD Glucose-170* UreaN-14 Creat-0.8 Na-138
K-4.8 Cl-103 HCO3-27 AnGap-13
[**2150-2-25**] 11:47AM BLOOD Glucose-195* UreaN-14 Creat-0.8 Na-138
K-5.2* Cl-105 HCO3-27 AnGap-11
[**2150-3-12**] 07:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.3 Iron-38*
IMAGING:
Head CT [**2-25**]:
IMPRESSION:
1. Large mixed but predominantly hyperdense left extra-axial
collection
consistent with acute subdural hematoma with gyral and lateral
ventricular
effacement, 9- mm rightward shift of midline structures and left
uncal
herniation.
2. Internal relatively low-attenuation foci may represent
non-clotted blood
from hyperacute hemorrhage, related to active bleeding.
3. Small right frontal extra-axial, likely subdural hematoma.
4. No fracture.
Head CT [**2150-2-25**] (post-evacuation):
IMPRESSION:
1. Status post virtual-complete evacution of left convexity
subdural hematoma with expected post-surgical changes including
bifrontal subdural
pneumocephalus.
2. Unchanged subdural blood layering along the tentorial
margins, as
described.
Head CT [**2150-3-4**]
IMPRESSION: Status post evacuation of subdural hematoma layering
over the
left cerebral convexity, without evidence of new intracranial
hemorrhage,
mass effect or herniation. The CSF-atttenuation fluid,
occupying the more anterior portion of the left frontal extra-
axial space, was present on the initial scan of [**2150-2-25**], and may
reflect decompression and re-expansion of pre-existent
compartmentalized subdural space, or true hygroma.
Head CT [**2150-3-13**]
FINDINGS: The patient is status post left frontoparietal
craniotomy with
expected amount of pneumocephalus, which has decreased compared
to the prior study. There is a small amount of remaining blood
products in the left frontal convexity consistent with expected
evolution of left subdural
hematoma. There is no evidence of new hemorrhage, mass effect,
or major
vascular territory infarction. There is no hydrocephalus or
herniation. There has been an interval decrease in left
frontoparietal subgaleal soft tissue edema. Visualized paranasal
sinuses and mastoid air cells remain well aerated. As before, no
lens is identified within the right globe.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or major
vascular territory infarction.
2. Status post craniotomy with expected evolution in remaining
blood products and decrease in pneumocephalus.
Brief Hospital Course:
#Bifrontal subdural hematoma evacuation - The patient did well
postoperatively following left craniotomy and evacuation of SDH
on [**2150-2-25**]. Neurological exam remained normal. Blood pressure
was closely monitored. Primary seizure prophylaxis was achieved
initially with dilantin and then with keppra, to be continued
after discharge. Heparin gtt was started on POD#5 followed by
coumadin on POD#8. Therapeutic INR was achieved without any
evidence of progression of SDH by CT. Physical therapy did not
recommended any post-discharge services. He will have his INR
checked 5 days after discharge. The patient will follow up with
neurosurgery 4 weeks after discharge.
.
#Mechanical mitral valve - TTE on [**3-2**] showed a well-seated
prosthesis with normal disc motion and transvalvular gradients,
without MR. Heparin bridge to therapeutic anticoagulation with
warfarin was achieved, as above, with a goal INR 2.5-3.5. The
patient was instructed to abstain from alcohol or starting new
medications until a stable coumadin level is established. He
will continue to be managed by the [**Company 191**] ACMS. It was recommended
that he follow up with his cardiologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 9083**] of [**Location (un) 9084**], MA.
.
#DMII - Serial elevated fasting glucose confirmed the diagnosis
of DMII. Metformin was started and well-tolerated prior to
discharge.
.
#CAD - Restarted aspirin prior to discharge. [**Month (only) 116**] benefit from
initiating beta-blockade as an outpatient if reactive airway
disease permits.
.
#Iron-deficiency anemia - Hematocrit remained stable, obviating
the need for blood transfusion. [**Month (only) 116**] benefit from iron
supplementation as outpatient. Outpatient colonoscopy
recommended.
.
#COPD - Continued the outpatient regimen.
Medications on Admission:
ASA 81 mg
Albuterol INR
Advair 500/50 [**Hospital1 **]
Symbicort 160/4.5 [**Hospital1 **]
Lasix 40 mg daily
Singulair 10 mg daily
Simvastatin 20 mg daily
Spiriva 18 mcg daily
Warfarin 15 mg daily
Ranitidine 150 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Ambien 10 mg QHS/PRN insomnia
Colchicine daily/PRN gout flare
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: Two
(2) Tablet PO every twelve (12) hours.
Disp:*28 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation twice a day.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain: as needed for gout flare.
9. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1) Acute bilateral subdural hematoma
2) Mechanical mitral valve replacement
3) Type II Diabetes
4) Iron deficiency anemia
Secondary
1) Coronary artery disease
2) Chronic obstructive pulmonary disease
3) Hyperlipidemia
4) Gout
Discharge Condition:
Asymptomatic with stable vital signs and normal neurological
exam.
Discharge Instructions:
You were admitted to the hospital after a fall with bleeding
outside of the brain, also known as subdural hematoma. Surgery
to remove the blood was performed on [**2150-2-25**] without
complications.
Please follow these recommendations for dosing your coumadin:
If your INR upon discharge is 2.5-3.5, take the following doses
of coumadin:
-10 mg Saturday and Sunday nights
-12.5 mg Monday night
-10 mg Tuesday night
-12.5 mg Wednesday night
-Have your coumadin level (INR) checked at [**Hospital3 **] on
Thursday, [**3-19**] and sent to the [**Hospital3 **]
on Thursday for further coumadin dosing.
Please continue to take Fiorecet for headaches until your INR
has stabilized. Fiorecet can affect the INR and your dose of
Fiorecet should be the same until you see Dr. [**Last Name (STitle) **] who will
decrease it.
Please do not take aspirin when you are discharged. You can
resume taking this 1 week after discharge.
**Please notify the [**Hospital3 **] Anticoagulation
[**Hospital 9085**] Clinic of any new medications.
**Please avoid alcohol until a stable dose of coumadin is
established.
You were also diagnosed with type II diabetes and started on a
medication called metformin (glucophage) to treat this
condition.
The following medication changes were made:
1) Keppra (Levetiracetam) was started to prevent a seizure.
2) Metformin (Glucophage) was started to treat diabetes.
3) Fiorecet 2 tablets every 12 hours for headaches.
The following are recommendations from your neurosurgery team:
?????? 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.
?????? 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.
?????? You have been discharged on Keppra (Levetiracetam) but you
will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Neurosurgery within 4 weeks' time.
??????Inform the person who books your appointment that you will need
a CT scan of the brain without contrast prior to the
appointment.
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-6**] weeks. Please follow-up
with the [**Hospital3 **] for your coumadin dosing.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-5-15**] 2:40
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2150-5-29**] 9:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2150-5-29**] 10:00
Completed by:[**2150-3-15**]
ICD9 Codes: 4280, 496, 2749, 4019 | [
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train_19320 | completed | eb880309-5cc0-48a9-88b8-ee07c3e67402 | Medical Text: Admission Date: [**2157-2-13**] Discharge Date: [**2157-2-17**]
Date of Birth: [**2074-3-13**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Mental status change
Major Surgical or Invasive Procedure:
[**2157-2-14**]: Left burr hole evacuation of a chronic subdural
hematoma
History of Present Illness:
This is a 82 year old female well known to this service who
presents today from [**Hospital6 8283**] after a fall in
the bathroom. She denies hitting her head. Following the fall
she was reported to have slurred speech and was slightly
confused. The patient had a Head Ct which revealed stable left
sided subdural hematoma and was transferred here for further
evaluation and treatment. The patient has a new skin tear on
her
anterior shin from the fall. The family is at the patient's
bedside and reports that the patient is now back at her baseline
mental status.
The patient denies, weakness, numbness, tingling sensation,
hearing or vision disturbance, bowel or bladder dysfunction.
Past Medical History:
PMH: frequent falls, dementia w/ dysarthria/broca's aphasia,
lyme
disease, L hand contracture, hypothyroid
PSH: C3 laminectomy, C5 and C6 fusion/laminectomy from fall and
MVC
Social History:
The patient was born in [**State 4260**]. She then moved to
[**State 18250**]. She also has a house on [**Hospital3 4298**] where she is
living now near her daughter who also live on [**Hospital3 4298**].
Her husband died two or three years ago, the patient was not
clear when, of heart disease. She has five children. She plays
tennis and likes to read. Smoking, none. Alcohol, she loves red
wine and drinks about three and ounces at a time, may be four
times a week. She likes to walk three to five times a week. She
is DNR/DNI. Daugher is the HCP.
Family History:
NC
Physical Exam:
PHYSICAL EXAM (on Admission)
O: T: 97.6 BP: 173/85 HR:71 R:18 O2Sats96% 2 liters
Gen: comfortable
HEENT: Pupils: [**3-4**] EOMs:intact
Neck: Supple.
Extrem: Warm and well-perfused.new large skin tear on left
anterior shin
Neuro:
Mental status: Awake and alert, cooperative and pleasant but
does
not follow all aspects of the exam,slightly vague affect
Orientation: Oriented to person only
Recall: unable to perform
Language: Speech fluent
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 patient is antigravity and appears, very
pleasant but does not fully participate in motor exam. No
pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: patient does not participate
Upon discharge:
PERRL, Moves all extremities spontaneously, confused
Pertinent Results:
Blood
[**2157-2-14**] 03:05AM BLOOD WBC-4.7 RBC-4.20 Hgb-12.9 Hct-38.6 MCV-92
MCH-30.7 MCHC-33.4 RDW-13.4 Plt Ct-211
[**2157-2-14**] 03:05AM BLOOD Glucose-124* UreaN-11 Creat-0.7 Na-139
K-3.6 Cl-107 HCO3-25 AnGap-11
[**2157-2-14**] 03:05AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
Urine
[**2157-2-14**] 12:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2157-2-14**] 12:30AM URINE RBC-2 WBC-115* Bacteri-NONE Yeast-NONE
Epi-4
Imaging studies:
CXR [**2157-2-14**]
FINDINGS: There is an irregularity along the base of the fifth
metacarpal,
suspected to represent a tug lesion associated with enthesopathy
rather than trauma. There is also a bridging osteophyte at the
joint between the medial cuneiform and first metatarsal. A tug
lesion is also noted along the lateral malleolus. Spurring is
likewise noted along the superior margin of the patella. The
bones appear demineralized.
IMPRESSION: Bony demineralization. No evidence of fracture.
Head CT [**2157-2-15**]
IMPRESSION:
1. Decrease in size of left subdural hematoma with slight
decrease in
rightward shift of the normal midline structures.
2. Expected postoperative pneumocephalus.
3. No evidence of new hemorrhage.
Head CT [**2157-2-17**]
IMPRESSION: Interval craniotomy with partial evacuation of
subdural
collection, now significantly decreased in size with improved
mass effect and
shift of midline structures.
Brief Hospital Course:
82 year old female with recent admission/discharge for SDH
(without intervention at that time) who presented on [**2-13**] from
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] Hospital after a fall in the bathroom and
question seizure activity. Head CT was stable in comparison to
the Head CT from [**2157-2-10**].
#Neuro:
- started Keppra 500mg [**Hospital1 **] for question seizure. She was made
NPO on [**2157-2-13**] and underwent burr hole for subdural hematoma
evacuation on [**2157-2-14**]. Post-op exam remained stable. Repeat head
CT on day of discharge on [**2-17**] was stable with some expected
pneumocephalus, but decreased midline shift.
# ID:
- U/A showing increased WBC, patient placed on Cipro. Culture
showed alpha streptococcus or Lactobacillus sp. She should
continue on this medicaition for 7 days.
# Cardiac:
- patient is being discharged on home doses of Digoxin and
Diltiazem.
# Nutrition:
- Patient takes an adequate oral diet with assistance.
# s/p Fall:
- tib/fib xray not showing Fx.
Patient is being discharged with instructions to follow up with
us in two weeks.
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet 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).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. memantine 10 mg Tablet Sig: One (1) Tablet PO daily ().
6. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
7. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue as previously prescribed.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. memantine 10 mg Tablet Sig: One (1) Tablet PO QD ().
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. levothyroxine 88 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO four times
a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] of Frsh pond
Discharge Diagnosis:
Left chronic subdural hematoma with compression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair with a mild shampoo, we recommend baby
shampoo.
?????? 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 Keppra (Levetiracetam), you will not
require blood work monitoring.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
without contrast.
?????? You will / will not need an MRI of the brain with/ or without
gadolinium contrast.
Followup Instructions:
Please follow-up with Dr [**First Name (STitle) **] in 2 weeks with a Head CT w/o
contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment.
Your sutures will need to be removed in [**7-12**] days from the date
of your surgery. This can be done by your primary care
physician, [**Name10 (NameIs) **] rehab or you can make an appointment to come to
our office.
Completed by:[**2157-2-17**]
ICD9 Codes: 5990, 2449 | [
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train_20421 | completed | 949f5c9f-a5e8-4c52-80ad-2c0921f19a95 | Medical Text: Admission Date: [**2103-5-25**] Discharge Date: [**2103-6-4**]
Date of Birth: [**2024-10-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2103-5-29**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Epic Porcine
Valve), Single Vessel Coronary Artery Bypass Graft(LIMA to LAD),
and Maze Procedure.
History of Present Illness:
Mrs. [**Known lastname 111659**] is a 78 year old female with PMHx of HTN,
COPD/Asthma, paroxysmal AF, PVD, s/p bilateral carotid
endarterectomies and aortic stenosis who was referred for right
and left heart cath in the setting of worsening SOB. She was
previously seen by Dr. [**Last Name (STitle) 1911**] after being hospitalized
with progressive PND, orthopnea, SOB and peripheral edema. Pt
presented to OSH repeatedly with RLQ pain and lower extremity
edema. Pt had some symptom relief with lasix and was discharged
on Lasix 40mg daily. Pt denies any chest discomfort, or
presyncope. She has some intermittent palpitations that she
associates with her Afib. Pt underwent an echo on [**2103-5-16**]-normal
LV size and function, mild mitral regurgitation and LVEF of 65%.
Aortic valve had three leaflets, was calcific with severe
stenosis. The peak gradient was 84 mmHg, the mean gradient was
60 mmHg and there was mild AI. There was left atrial
enlargement.
Past Medical History:
# Severe aortic stenosis
# Paroxysmal atrial fibrillation
# Hypertension
# s/p bilateral CEAs
# CRI, ?baseline 1.4-1.9, most recently 1.4 [**2103-5-14**]
# h/o TIA x3, last 20 years ago
# Scarlet fever as an infant
# Rheumatic fever in her teens
# S/P ulnar nerve removal from her left arm
# S/P left knee arthroscopy
# S/P bilateral cataract surgery
# Asthma
# S/P cyst removal bilateral breasts
# Spinal stenosis/ several ruptured discs
# h/o UTI
# h/o pneumonia
# Hearing impaired
# Depression
Social History:
She is a widow and lives alone. Retired administrative
assistant. She has four grown children. She does not smoke (quit
30 yrs ago, 4 ppdx20 yrs) but drinks a glass of wine nightly.
Family History:
Brother died of MI at age 36
Physical Exam:
VS: T-98.5 BP 140/53 HR 62 RR 18 Sats 95% RA
Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Carotid bruits bilaterally (radiating from precordium)
CV: Irreg/irreg with gr 3 harsh SEM radiating across
pre-cordium.
Chest: Resp were unlabored, no accessory muscle use. Bilateral
crackles apprec at bases, otherwise no wheezes, moving air well
Abd: Soft, NTND. No HSM or tenderness. Obese
Ext: No c/c/e. Right groin stable with no femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2103-5-29**] Intraop TEE:
PREBYPASS - No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. There is severe
aortic valve stenosis (area <0.8cm2). Mild to moderate ([**12-20**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen.
POSTBYPASS - There is preserved biventricular systolic function.
There is a well seated, well functioning bioprosthesis in the
aortic position. (Biocor #21 Epic supranullar). No AI is
visualized. The study is otherwise unchanged from the prebypass
period.
[**2103-6-4**] 05:33AM BLOOD WBC-10.9 RBC-3.04* Hgb-9.4* Hct-26.9*
MCV-88 MCH-31.0 MCHC-35.1* RDW-16.0* Plt Ct-181
[**2103-6-3**] 06:50AM BLOOD WBC-9.2 RBC-3.01* Hgb-9.0* Hct-26.5*
MCV-88 MCH-30.0 MCHC-34.1 RDW-16.1* Plt Ct-144*
[**2103-6-4**] 05:33AM BLOOD PT-15.6* PTT-34.5 INR(PT)-1.4*
[**2103-6-3**] 06:50AM BLOOD PT-14.4* PTT-40.2* INR(PT)-1.3*
[**2103-6-4**] 05:33AM BLOOD Glucose-92 UreaN-34* Creat-1.5* Na-136
K-4.0 Cl-93* HCO3-37* AnGap-10
[**2103-6-3**] 06:50AM BLOOD UreaN-33* Creat-1.5* K-3.9
[**2103-6-2**] 07:05AM BLOOD UreaN-32* Creat-1.9* K-4.0
[**2103-6-1**] 05:15AM BLOOD Glucose-93 UreaN-27* Creat-1.8* Na-131*
K-3.7 Cl-96 HCO3-27 AnGap-12
CHEST (PA & LAT) [**2103-6-2**] 9:23 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman s/p AVR/CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
CLINICAL HISTORY: Status post AVR and CABG.
CHEST
There is evidence of previous CABG. Heart remains enlarged. A
left effusion is present. Extensive atelectasis and a possible
infiltrate in the right lower and left lower lobe is present.
Brief Hospital Course:
Mrs. [**Known lastname 111659**] was admitted to the cardiology service and
underwent cardiac catheterization which confirmed severe aortic
stenosis with a 60mmHg gradient and valve area of 0.6cm2.
Coronary angiography revealed a right dominant system and a 60%
lesion in the proximal left anterior descending artery. Cardiac
surgery was therefore consulted and further evaluation was
performed. Given her paroxysmal atrial fibrillation, she was
maintained on intravenous Heparin. Carotid ultrasound found only
mild to moderate disease of both internal carotid arteries.
Preoperative course was otherwise uneventful with mild
improvement in renal function. Prior to surgery, she was
transfused with PRBC for a hematocrit of 27%. On [**5-29**], Dr.
[**Last Name (STitle) **] performed an aortic valve replacement, single vessel
coronary artery bypass grafting and Maze procedure. For surgical
details, please see seperate dictated operative note. Following
the operation, she was brought to the CVICU for invasive
monitoring. Within 24 hours, she awoke neurologically intact and
was extubated without incident. Amiodarone and Warfarin were
resumed. She was given additional PRBC to maintain hematocrit
near 30%. She otherwise maintained stable hemodynamics and
transferred to the SDU on postoperative day two. She converted
back to a rate controlled atrial fibrillation. She was started
on lovenox while her INR was subtherapeutic. She was ready for
discharge to rehab on POD #6.
Medications on Admission:
Amio 200 qd, Norvasc 10 qd, HCTZ 25 qd, Lasix 40 qd, Tramadol
prn, Spiriva 18 mcg qd, Albuterol Diskus, Calium 600 [**Hospital1 **],
Flovent, Olmesartan 40 qd, Crestor 10 qd, Trazadone 50 qhs,
Warfarin, Citalopram 40 qd
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. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): until INR > 2.0.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily):
check INR [**6-5**] and continue lovenox until INR > 2.0.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Chronic Diastolic Congestive Heart Failure
Aortic Stenosis
Coronary Artery Disease
Hypertension
Paroxsymal Atrial Fibrillation
Chronic Renal Insufficiency
Cerebrovascular Disease - history of TIA's
Depression
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-24**] weeks, call for appt
Dr. [**Last Name (STitle) 1911**] in [**1-21**] weeks, call for appt
Dr. [**Last Name (STitle) 1159**] in [**1-21**] weeks, call for appt
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 16827**]
Date/Time:[**2103-8-1**] 11:20
Completed by:[**2103-6-4**]
ICD9 Codes: 4241, 5849, 4280, 5859, 496, 311, 4439, 2449 | [
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train_19924 | completed | e69549bd-0bd0-49ab-9d89-4f3c649b69eb | Medical Text: Admission Date: [**2195-1-25**] Discharge Date: [**2195-1-30**]
Date of Birth: [**2145-9-22**] Sex: M
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old man
with a history of esophageal cancer first diagnosed in [**2194-5-2**] status post chemotherapy and radiation, who underwent an
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy on [**2194-11-13**] by Dr. [**Last Name (STitle) 175**] at this
institution. Since that operation, the patient's
postoperative course has been complicated by a
methicillin-resistant Staphylococcus aureus wound infection,
wound dehiscence, and creation of a fistula and diversion
after breakdown of his anastomosis. The patient had a
prolonged hospital stay at that time, but recovered and was
discharged to rehabilitation. While at rehabilitation the
patient continued on his long-term vancomycin therapy, which
was completed on [**2195-1-21**]. On that date, the patient began
to experience fever and mental status changes, and was
transferred to [**Hospital3 417**] Hospital, where he was found to
be frankly septic. Once the patient's history was known, he
was transferred to the [**Hospital1 69**]
for further work-up.
HOSPITAL COURSE: Upon presentation at our facility the
patient was found to be frankly septic, in need of blood
products, which were given. The patient required near
immediate intubation, which was undertaken. Extensive
work-up of the patient included CT scan of his abdomen and
chest, magnetic resonance imaging scan of his abdomen,
bronchoscopy and multiple cultures, revealing that the
patient was floridly septic, although a discrete source was
not clearly identified.
The patient was started on broad-spectrum antibiotics,
vancomycin, levofloxacin, and Flagyl. The patient's fistula
was found to be draining frank pus, although no discrete
drainable fluid collection was found in his chest.
Over the next few days the patient remained in the intensive
care unit intubated, in extremely serious condition, not
improving on his antibiotics. Discussions were undertaken
with the family and he was made DNR, and the decision was
made to transfuse no new blood products and to start no
pressors. The patient's white count continued to rise. He
was found to be in disseminated intravascular coagulation and
appeared to be having liver failure. His blood gases
demonstrated that he was persistently severely acidotic.
The patient's course continued to deteriorate and on the
morning of [**2195-1-30**] the patient was found to still be
spiking fevers, was hemodynamically unstable, and to be in
severe disseminated intravascular coagulation. The patient
succumbed and was pronounced dead at 10:45 AM on [**2195-1-30**]. The family was notified of the death, as well as the
attending surgeon, and consent was obtained for a postmortem
examination.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2195-1-30**] 11:24
T: [**2195-1-30**] 12:03
JOB#: [**Job Number 35106**]
ICD9 Codes: 0389, 486 | [
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train_19459 | completed | 3811c53a-d697-4b5a-9a7d-ea899f8527f3 | Medical Text: Admission Date: [**2205-1-22**] Discharge Date: [**2205-2-1**]
Date of Birth: [**2152-7-13**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Valium / Allopurinol
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
DCCV
History of Present Illness:
52 YO female with Hx of CHF (EF55%) seen by Dr. [**First Name (STitle) 437**] in
Cardiology clinic , COPD (FEV1 1.8), Hx of afib, HTN, PVD, CRI
who c/o 1-2 weeks of increased dyspnea on excertion. Patient
states her symptoms have been getting worse over the past few
days. She also noticed that she had increased swelling of her
legs and abdomen. She states she has been taking her lasix but
not too much UOP. She came to the ED because her symptoms were
not improving and got nebulizer treatments, steroids, and dose
of abx in the ED. She was breifly on BiPap in the ED and
transferred to the [**Hospital Unit Name 153**] where her symptoms quickly improved and
she was put back on nasal cannula.
.
Pt uses 2L O2 at home when needed and uses inhalers when needed
at home. She denies any fever or chills. She describes her
dyspnea as "chest tightness."
(+) PND and has 2 pillow orthopnea. No Palpitation.
Also in the ED patient EKG was noted to be in Afib.
Past Medical History:
1. CHF: history of both right- and left-sided CHF with
significant pulmonary hypertension. Most recent cardiac
catheterization in [**1-/2201**] revealed PCW of 32, PAP of 78/33, RA
mean 22 and normal cardiac output. Last echo on [**4-7**],
showed normal left ventricular wall thickness, cavity size, and
systolic function (LVEF>55%). Right ventricular chamber size and
free wall motion were also normal. A left-to-right shunt across
the
interatrial septum is seen at rest. A small secundum atrial
septal defect (ASD) is present.
2. Hypertension
3. COPD: Her PFT??????s on [**2201-9-7**] were within normal limits
(FEV1=1.8 L, FVC= 2.44 L)
4. Atrial fibrillation: Since [**2202-12-11**]
5. ASD: a left-to-right shunt across the interatrial septum was
first observed on echo on [**2200-12-17**].
6. Positive PPD in [**2195**] with negative chest x-ray; no
prophylaxis given.
7. Peripheral vascular disease: s/p left femoral-popliteal
bypass on [**11/2195**]
8. Renal insufficiency: Elevated creatinines since [**2195**],
baseline creatinine is 2.5 on [**2203-8-22**]
9. Gout: First episode in [**2202-12-4**] during hospitalization
for CHF exacerbation.
10. Eczematous dermatitis: Biopsied in [**2203-7-21**], reaction to
allopurinol
11. Fibroid uterus: diagnosed during pelvic ultrasound on
[**2200-5-1**].
12. Duodenitis
Social History:
Patient works as a bus monitor. She lives with her boyfriend.
She quit smoking 4 years ago after a 26-pack-year history. She
drinks socially and denies illegal drug use.
Family History:
Mother died of heart problems at age 27. Grandmother died of
heart problems at 73. Father had kidney problems and died in his
50??????s.
Physical Exam:
T 98.4 BP 149/79 HR 89 RR 20 O2Sat 94% on 2L NC
Gen: Patient sitting up in bed [**Location (un) 1131**] magazine, able to talk
w/o difficulty
Heent: PERRL, EOMI, OP clear, MMM
Neck: Increased JVD not appreciated
Lungs: Bibasilar crackles, no wheezes
Cardiac: Irregularly Irregular, S1/S2 no murmurs
Abdomen: Obese, soft, +BS
Ext: Healed scar on LE B/L, +1 pitting edema upto shin B/L
Neuro: AAOx3
Pertinent Results:
CXR: AP UPRIGHT CHEST RADIOGRAPH: Lung volumes are low. There is
moderate stable cardiomegaly. A left retrocardiac opacity
represents
atelectasis and/or consolidation. No demonstrable pleural
effusions are
seen. No evidence of pneumothorax. Osseous structures are
unchanged.
[**2205-1-23**] 06:19AM BLOOD WBC-6.3 RBC-3.90* Hgb-10.0* Hct-31.9*
MCV-82 MCH-25.5* MCHC-31.3 RDW-16.7* Plt Ct-263
[**2205-1-23**] 06:19AM BLOOD Neuts-87.2* Lymphs-10.7* Monos-1.8* Eos-0
Baso-0.2
[**2205-1-23**] 06:19AM BLOOD PT-14.4* PTT-25.8 INR(PT)-1.4
[**2205-1-23**] 06:19AM BLOOD Glucose-146* UreaN-46* Creat-3.2* Na-142
K-4.4 Cl-103 HCO3-26 AnGap-17
[**2205-1-22**] 09:35AM BLOOD CK(CPK)-68
[**2205-1-22**] 09:35AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-4537*
[**2205-1-22**] 03:50PM BLOOD CK(CPK)-15*
[**2205-1-22**] 03:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2205-1-22**] 08:03PM BLOOD CK(CPK)-59
[**2205-1-22**] 08:03PM BLOOD CK-MB-1 cTropnT-<0.01
Brief Hospital Course:
52 YO female with Hx of diastolic CHF, A fib, COPD admitted with
shortness of breath which has improved, attempted chemical
cardioversion to SR with propafenone.
.
1. Afib - New onset, TEE without clot. Started on propafenone on
[**1-24**] --> [**1-25**] still in AF 80s. [**2205-1-27**] - DCCV after 3 days of
Propafenone. Patient converted to sinus. Patient continued on
propafenone 150mg tid and carvedilol. Started on coumadin by
[**Hospital Unit Name 153**] team. Bridged with Heparin. INR still sub-therapeutic at
1.9 at time of discharge. Coumadin dose increased to 7.5 mg QHS.
She will have INR checked in 2 days as an out-patient. On day
of discharge she went back into a fib, however, she remained
rate controlled. She was discharged on amlodipine and Coreg. She
will follow-up with EP as an out-pt.
.
2. Acute on CRI - Cr up to 3.6 when discharged, BUN 48, likely
secondary to overdiuresis. Lasix IV was held with plan to
restart at Lasix 80mg po qd when discharged. Should have BUN/Cr
checked by PCP in the week following her discharge.
.
3. Heart failure - Hx of diastolic heart failure probably
exacerbated with a fib, symptoms improved when patient was
cardioverted.
.
4. HTN - BP well controlled during her stay. Lisinopril was
discontinued due to her worsening renal failure.
.
5. GERD - Recent EGD which showed duodenitis. Hct stable during
her admission. Patient received pantoprazole. Aspirin was held.
.
6. COPD: Stable, on O2 prn at home. Ipratroprium and albuterol
continued prn.
.
Medications on Admission:
Coreg 75 mg twice daily
Norvasc 10 mg twice daily
lisinopril 10 mg once daily,
folic acid,
Lipitor 20 mg once daily,
Protonix 40 mg once daily,
Imdur 60 mg once daily,
Lasix 80 mg in the morning and 40 mg in the afternoon,
colchicine as needed
Flovent
Atrovent prn
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: Six (6) Tablet PO BID (2 times
a day).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO HS (at bedtime).
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Propafenone 150 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime):
You should have your INR checked regularly with a goal of [**3-8**].
Disp:*30 Tablet(s)* Refills:*2*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Please draw PT/INR, BUN, creatinine, potassium on Monday [**2-6**] and send results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**], [**Telephone/Fax (1) 250**].
15. Return to [**Known lastname 14554**] was hospitalized under my care from [**2205-1-22**] -
[**2205-2-1**]. She may return to work as tolerated beginning [**2205-2-2**]
as tolerated. For further questions, please contact myself or
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] at [**Telephone/Fax (1) 250**].
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation
Diastolic Heart failure
Acute Renal Failure
Chronic Renal Failure
Discharge Condition:
Good- able to ambulate and perform ADLs without assistance.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1 liter per day.
Please check INR, please call your PCP SHIP,[**Name9 (PRE) 674**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 250**]
to arrange blood draws.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] (at [**Company 191**]) in [**2-5**] weeks. You
should have your INR/creatinine/potassium drawn with the
accompanying lab slip and have results sent to her if you are
not planning on going to the [**Company 191**] laboratory.
You also have follow up with DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**]
Date/Time:[**2205-3-4**] 9:30 from cardiology.
You also have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] which you
scheduled.
ICD9 Codes: 5849, 5859, 496, 4280, 2859 | [
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train_19503 | completed | cf44d957-fa0d-44ca-b856-d367dd7b8568 | Medical Text: Admission Date: [**2178-5-7**] Discharge Date: [**2178-5-12**]
Service: CME
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female, with a past medical history of hypertension, chronic
atrial fibrillation, chronic stable angina, who presents to
the Emergency Department with shortness of breath. Of note,
the patient was recently hospitalized at [**Hospital1 18**] in late-[**Month (only) 116**]
with chest pain that radiated to the neck, was ruled out for
MI, and was found to have a normal P-MIBI with an estimated
ejection fraction of 63 percent, and no wall motion
abnormalities. The patient did well at the [**Hospital 100**] Rehab
Nursing Home following discharge, until approximately the
morning of admission when she began to experience worsening
shortness of breath.
In the ED, her heart rate was noted to be in an AFIB rhythm
at a rate of up to 160, and the patient's physical exam, as
well as chest film were thought to be consistent with CHF.
The patient was given Lasix, as well as IV diltiazem 20 mg in
the ED, though subsequently became hypotensive and briefly
required a dopamine drip for blood pressure stabilization.
In addition, CPAP was administered for worsening hypoxia in
the ED.
PAST MEDICAL HISTORY: Hypertension.
Atrial fibrillation, chronic. The patient is anticoagulated
on Coumadin.
Congestive heart failure.
DVT, status post IVC filter placement.
Hypothyroidism.
Anemia.
History of breast cancer, status post mastectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Zocor 20 mg qd.
2. Sorbitol solution 30 mg hs.
3. Enteric-coated baby aspirin 81 mg qd.
4. Digoxin 0.0625 qd.
5. Colace.
6. Lasix 40 mg qd.
7. Prevacid 30 mg qd.
8. Synthroid 88 mcg qd.
9. Zestril 20 mg qd.
10.Citrucel.
11.Metoprolol 25 mg [**Hospital1 **].
12.Nitro-Derm patch 0.6 mg.
13.Senna.
15.Aldactone 25 mg qd.
16.Coumadin 4 mg q hs.
17.Milk of Magnesia.
SOCIAL HISTORY: The patient is a resident of the [**Hospital3 1761**] facility. She has several children who are
involved with her care. She denies any alcohol intake, does
not smoke cigarettes, and has no history of IVDA.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101 (rectal),
pulse 143 and irregular, blood pressure 113/69, respiratory
rate 26, O2 sat 100 percent on CPAP. The patient was
tachypneic with moderate accessory muscle use and noted to be
in moderate distress. Pupils were equally round and reactive
to light. Extraocular muscles were intact. There was no JVD
in upright position. She had an irregularly irregular heart
rhythm which was tachycardic, and there was a II/VI
holosystolic murmur present at the apex. There were
bibasilar crackles present on exam. Abdomen soft, mildly
distended, tender in the left lower quadrant though. There
was no rebound and no guarding. There were no masses. She
had no peripheral edema. No calf tenderness.
LABORATORIES ON ADMISSION: Sodium 139, potassium 3.7,
chloride 96, bicarb 23, BUN 29, creatinine 1.1, glucose 202,
anion gap 20, white count 4.6, with 80 neutrophils and 8
bands, 37 hematocrit, platelets 74, digoxin level 0.5, TSH
7.1. A UA demonstrates a nitrite negative, leukocyte
esterase negative, with a sediment of 0-2 red cells and [**1-30**]
white cells, though many bacteria were present on sediment.
ECHOCARDIOGRAM: Revealed an EF of 20 percent with akinesis
of the apical half of the left ventricle. There was also 1
plus AR, 2 plus MR, and 3 plus TR.
EKG: Demonstrated atrial fibrillation at a rate of 160 with
borderline left axis, Q waves present in V1, V2 (old), with [**Street Address(2) 107861**] relation to V2.
CHEST FILM: Demonstrated cardiomegaly, as well as bilateral
pulmonary edema, and small bilateral effusions.
KUB: Demonstrated slightly dilated small bowel loops in the
lower abdomen with a relative paucity of gas in the colon
consistent with prior partial small bowel obstruction.
HOSPITAL COURSE:
1. UROSEPSIS: The patient was febrile on admission, had a
significant bandemia, and was noted to have many bacteria
in her urine sediment. Urine culture revealed
pansensitive Citrobacter freundii greater than 100,000
organisms. The patient was begun on intravenous
ceftriaxone empirically 1 mg IV qd. Prior to receiving
the result of this culture, the patient was also begun on
empiric vancomycin and received 1 dose of 1 gm. However,
once the urine culture results were apparent, the
vancomycin was not continued. The patient was initially
hypotensive and required significant intravenous saline
boluses to maintain adequate blood pressure. Likewise,
the patient initially required phenylephrine to maintain
adequate blood pressure. The patient improved
significantly with antibiotic and intravenous saline, and
it was possible to wean off the Neo-Synephrine on the 13
of [**Month (only) **]. The patient remained afebrile for 72 hours prior
to discharge. The patient maintained adequate blood
pressure's off Neo-Synephrine for the 48 hours prior to
discharge, and it was possible to reinitiate her CHF
regimen, including beta blocker and ACE inhibiting
medications. The patient will be switched to oral
antibiotics on the day of discharge, and will complete a
10-day course of antibiotics for her urosepsis.
1. ACUTE RENAL FAILURE: The patient was noted to be
significantly dehydrated on admission presumably secondary
to her sepsis, and creatinine subsequently rose from her
baseline of 0.8 to maximum of 1.4 on the [**5-8**].
However, with ongoing intravenous saline boluses and
increasing PO intake, the patient's creatinine decreased
to 0.8 on the [**5-11**].
1. ATRIAL FIBRILLATION: The patient, as mentioned in HPI,
was noted to be in atrial fibrillation with rapid response
on admission. She was initially loaded with IV amiodarone
in the Emergency Department. However, the patient did not
tolerate the IV amiodarone well and became hypotensive
subsequently, and briefly required dopamine to maintain
adequate pressures. The amiodarone was discontinued on
admission to the CCU, and it was possible to wean off the
dopamine shortly thereafter. Nonetheless, the patient's
heart rate remained in the 100-130 range. The patient was
initially started on PO amiodarone 400 mg [**Hospital1 **]. However,
when it became possible to restart her metoprolol for rate
control, she maintained adequate rate control with heart
rates in the 90-120 range, and the amiodarone was
discontinued on the [**5-11**]. The patient was
maintained in a therapeutic INR range. However, as the
amiodarone, as well as her antibiotic interacted with her
Coumadin, her INR was noted to be supertherapeutic,
reaching a maximum level of 5.9 on the [**5-8**]. At
that point, the patient was given 5 mg of oral Vitamin K,
with subsequent decrease in her INR to 3.8. Her warfarin
was continued to be held until the [**5-12**], when it may
be started the evening of the 15 at her usual dose.
1. ISCHEMIA, RULE OUT MI: The patient was noticed to have a
significantly decreased ejection fraction with new wall
motion abnormalities on the admission echocardiogram which
was in striking contrast to the P-MIBI of just 1 month
prior. The patient ruled out for MI by serial negative
cardiac enzymes. Her CK ranged from 80-94. Though her
troponin-T was initially 0.48 and reached a maximum of
0.73, it was felt that this was more likely related to
congestive heart failure and demand ischemia in the
setting of rapid ventricular rate. The patient was
maintained on aspirin, statin, and was given prn morphine
over the first 2 days of admission for chest pain. The
patient was restarted on low dose beta blocker prior to
discharge.
As mentioned above, the patient's significantly different
cardiac function demonstrated on the echocardiogram, which
included an EF of less than 20 percent, with akinesis of the
apical half of the ventricle, as well as 1 plus AR, 2 plus MR
and 3 plus TR was felt to be new since her previous admission
of [**2178-3-28**]. It was felt that most likely she underwent a
myocardial infarction in between the 2 [**Hospital1 18**] admissions.
Alternatively, it is possible that the patient developed a
rate-related myopathy, given the rapid ventricular response
that she was evidenced to have on admission with rates up to
160.
1. HYPOTHYROID: The patient was maintained on her outpatient
dose of Synthroid.
1. ANEMIA: The patient's hematocrit remained stable over the
course of this admission. Her hematocrit ranged from 37
on admission to 34 the day prior to discharge.
1. THROMBOCYTOPENIA: The patient was noted to have a
platelet count of 74 on admission. However, DIC labs were
negative, and her subsequent platelet counts were in the
132-146 range which is close to her baseline. It was felt
that the initial platelet [**Location (un) 1131**] was most likely
erroneous. The patient was discharged in stable
condition.
DISCHARGE DIAGNOSES: Chronic atrial fibrillation.
Urosepsis.
Cardiomyopathy.
Hypothyroid.
Dehydration.
Anemia.
Mitral regurgitation.
Tricuspid regurgitation.
Aortic insufficiency.
Congestive heart failure.
FOLLOW UP: The patient will follow-up with her primary care
physician.
DISCHARGE MEDICATIONS:
1. Levothyroxine 88 mcg qd.
2. Colace.
3. Senna.
4. Pantoprazole ER 40 mg qd.
5. Simvastatin 20 mg qd.
6. Lactulose prn.
7. Trazodone 12.5 hs prn.
8. Digoxin 0.0625.
9. Warfarin 4 mg hs for a target INR of [**12-30**].0.
10.Enteric-coated aspirin 81 mg qd.
11.Toprol XL 25 mg qd.
12.Lisinopril 2.5 mg qd.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 4958**]
Dictated By:[**Last Name (NamePattern1) 8188**]
MEDQUIST36
D: [**2178-5-11**] 13:36:17
T: [**2178-5-11**] 14:36:40
Job#: [**Job Number **]
ICD9 Codes: 0389, 5990, 5849, 4111, 2875, 4254 | [
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train_16318 | completed | d52d9134-5927-4d6a-88c1-3bff5420d5db | Medical Text: Service: Date: [**2120-2-14**]
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female transferred from an outside hospital as a trauma-basic
alert following a fall down stairs. The paramedics found her
with the right lower extremity in a position such her ankle
was secured to the backboard near her right eye with an
obvious deformity in the right mid-shaft femur. She was
hemodynamically stable throughout.
PAST MEDICAL HISTORY:
1. Coronary artery disease, congestive heart failure with an
EF of 15%, coronary artery bypass graft, history of atrial
fibrillation.
2. History of DVT and previous pulmonary embolism.
3. Hypertension.
4. Previous hysterectomy.
5. Old right patellar fracture.
The patient was admitted to the trauma bay. She was afebrile
with stable vital signs. She had palpable distal pulses with
this extremity in this position. However, this was
immediately reduced and post-reduction, her foot remained
warm with palpable distal pulses. The patient's trauma
workup revealed a fracture of the proximal femur, as well as
a fracture of the distal femur on the side of the deformity.
Investigation of the C-spine revealed a new atlas fracture
and question of a DENS fracture could not be ruled out as new
but, potentially may have been old. During her time in the
radiology suite, the patient experienced a wide-complex
tachycardia for which she was started on a Lidocaine drip.
However, she later ruled out for a primary myocardial event.
The patient was transferred to the trauma surgical Intensive
Care Unit. Orthopedic consultation was obtained. The
orthopedist scheduled the patient for open reduction and
internal fixation of her femur later that evening. The
patient tolerated the procedure well. There were no
complications.
Postoperatively, the patient remained stable. The patient
had a Dobbhoff nasoenteric feeding tube placed and tube feeds
were started. She was a slow vent wean, however, eventually,
extubated and remained stable.
The patient's pulmonary status remained tenuous for several
days. She was kept in the Intensive Care Unit for aggressive
pulmonary toilet. Following her slow recovery in the
Intensive Care Unit, she was transferred to the floor, where
she continued to do well. She was afebrile with stable vital
signs. She was tolerating her tube feeds at goal.
Immediately before transfer to the floor, she went to the
Interventional Radiology Suite, where [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] inferior
vena caval filter was placed. Given her history of previous
pulmonary embolism and deep venous thrombosis. Consideration
was given to avoiding filter placement and just
anticoagulating her with Coumadin. However, she is deemed a
significant fall risk and this was thought to be a safer
alternative.
On the floor, she continued to do well. She became more
alert and oriented, tolerating tube feeds. She will be
discharged to rehabilitation.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient is discharged to
rehabilitation.
DISCHARGE DIAGNOSES:
1. Traumatic right femoral neck and distal femur fracture
status post open reduction and internal fixation.
2. C1 and C2 DENS fracture requiring hard collar
immobilization.
3. Status post inferior vena caval filter placement.
4. Coronary artery disease.
5. Congestive heart failure with ejection fraction of 15%.
6. Status post coronary artery bypass grafting.
7. History of pulmonary embolism and deep venous thrombosis.
8. Hypertension.
9. Status post hysterectomy.
10. Previous patellar fracture.
11. History of atrial fibrillation. During this admission,
the patient was found to be in wide complex normal sinus
rhythm.
DISCHARGE MEDICATIONS:
1. Metoprolol 100 mg p.o.b.i.d.
2. Lasix 20 mg p.o.q.d.
3. Zestril 2.5 mg p.o.q.d.
4. Acetylsalicylate acid 325 mg p.o.q.d.
5. Albuterol/Atrovent MDI 2 puffs q.4h.p.r.n.
6. Tube feed Impact with fiber at 60 cc an hour.
7. Digoxin 0.125 mg p.o.q.d.
8. Nitropatch 0.2 mg q.a.m. hold in the evenings.
9. Roxicet elixir 5 cc p.o.q.4h.p.r.n.
10. K-Phos 8 millimoles p.o.q.i.d. times two days.
The patient's nasoenteric tube should be flushed with 250 cc
free water q.12h. She is touchdown weightbearing on the
right lower extremity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2120-2-14**] 10:19
T: [**2120-2-14**] 10:30
JOB#: [**Job Number **]
ICD9 Codes: 4254, 2851 | [
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train_18295 | completed | ec2c1483-0e1c-4618-a6f5-5b12bf29703f | Medical Text: Admission Date: [**2169-9-6**] Discharge Date: [**2169-9-11**]
Date of Birth: [**2094-7-13**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**Last Name (un) 11974**]
Chief Complaint:
ICD firing three times
Major Surgical or Invasive Procedure:
VT Ablation
History of Present Illness:
Mr. [**Known lastname 57523**] is a 75 year old male with past medical history of
type2 DM, atrial fibrillation s/p AVN ablation and several AADs,
CAD complicated by systolic heart failure with LVEF of 25%,
ventricular tachycardia s/p ICD placement and VT ablation in
[**2164**] complicated by right iliac artery disection requiring
emergent angiography and stenting.
He woke up this morning with ICD shock. He does not report chest
pain, shortness of breath, palpatations or syncope prior to the
episode. He went to his PCP today where [**Name9 (PRE) 1543**] interrogation
was thought to be inappropriate. He was instructed to go home
and come to the ED if he has ICD shock. He did have ICD shock x
2 this evening without any associated symptoms. He called EMS
and was brought to [**Hospital3 **]. Labs at OSH were notable for
normal electrolytes, creatinine at baseline of 1.56, BNP of 193,
nomral CBC and troponin of 0.068. He was transferred to [**Hospital1 18**]
for further management.
In the ED, initial vitals were: 98.2 70 141/91 18 100% 2LNC. EP
was consulted who recommended increasing metoprolol to 100 mg
[**Hospital1 **], trending troponin and admission to [**Hospital1 **] after interrogation
revealed his ICD shocks were appropriate for 330 ms cycle length
ventricular tachycardia.
Past Medical History:
AAA - 4 cm per recent ultrasound
Peripheral Vascular Disease s/p iliac disection and stenting
[**2165-4-25**]
Prostate Cancer
Coronary Artery Disease s/p angioplasty
s/p pacemaker placement
GERD
Hyperlipidemia
Hypertension
Sciatica
Hyperthyroidism
Atrial Fibrillation
Type II diabetes
Stage III Chronic Kidney Disease
Social History:
Patient quit smoking in [**2158**]. He has a 10 pack year smoking
history. He occassionally has alcohol. He never uses other
drugs. He was never married. He is a priest and lives in a
monastary.
Family History:
His father did of a heart attack at age 46, his sister at age
59.
Physical Exam:
Admission Physical Exam:
VS: 98.0 134/80 88 18 98%RA
Gen: Elderly male, pale, lying in bed in no acute distress.
Oriented x 3, mood and affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm, left sided carotid bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
AICD site intact, well healed incision.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. Bilateral femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Physical Exam:
VS: t = 97.9, bp = 99/58 - 111/56, hr = 81, rr = 18, O2 sat =
99% on RA
General: Older Caucasian male, no acute distress, sitting up
easily this morning.
HEENT: Normocephalic, atraumatic. MMM. OP clear.
Neck: Supple. Nondistended JVD.
Heart: Regular rate, S1 and S2. No audible mumurs, rubs, or
gallops. AICD site intact with well healed incision.
Lungs: No increased WOB or accessory muscle use. Lungs clear
bilaterally to wheezes, rhonchi, rhales.
Abd: NABS, soft, nondistended. Nontender to palpation.
Ext: Warm to perfusion, no edema. Distal pulses diminished but
intact.
Pertinent Results:
Admission Labs:
[**2169-9-6**] 08:57PM BLOOD WBC-9.5 RBC-3.76*# Hgb-12.7*# Hct-36.6*#
MCV-97 MCH-33.8* MCHC-34.7 RDW-14.2 Plt Ct-222
[**2169-9-6**] 08:57PM BLOOD Neuts-77.1* Lymphs-14.6* Monos-5.7
Eos-1.7 Baso-0.8
[**2169-9-6**] 08:57PM BLOOD PT-32.3* PTT-41.8* INR(PT)-3.1*
[**2169-9-6**] 08:57PM BLOOD Glucose-118* UreaN-30* Creat-1.7* Na-140
K-4.0 Cl-102 HCO3-26 AnGap-16
[**2169-9-6**] 08:57PM BLOOD cTropnT-0.03*
[**2169-9-7**] 03:21AM BLOOD CK-MB-3 cTropnT-0.03*
[**2169-9-7**] 12:27PM BLOOD CK-MB-3 cTropnT-0.02*
[**2169-9-7**] 03:21AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
[**2169-9-6**] 08:57PM BLOOD TSH-7.1*
[**2169-9-7**] 12:27PM BLOOD T4-7.9
[**2169-9-6**] 08:57PM BLOOD Digoxin-0.8*
Discharge Labs:
[**2169-9-11**] 06:33AM BLOOD WBC-8.4 RBC-3.58* Hgb-11.7* Hct-35.3*
MCV-98 MCH-32.6* MCHC-33.2 RDW-14.2 Plt Ct-211
[**2169-9-11**] 06:33AM BLOOD Plt Ct-211
[**2169-9-11**] 06:33AM BLOOD Glucose-117* UreaN-34* Creat-1.8* Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
[**2169-9-11**] 06:33AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
Imaging
EKG ([**2169-9-7**]):
A-V sequential pacing with a very short A-V interval.
Ventricular paced
complex is of the appropriate left axis deviation, but with a
right
bundle-branch block pattern in the precordial leads consistent
with
biventricular pacing. Compared to the previous tracing of the
same date the overall rate has increased with uniform atrial
pacing rather than intermittent atrial sensing. Morphology of
the ventricular paced beats is unchanged.
CXR ([**2169-9-7**]):
FINDINGS: As compared to the previous radiograph there is no
relevant change. No pulmonary edema. No pneumonia. Borderline
size of the cardiac silhouette. Moderate tortuosity of the
thoracic aorta. Pacemaker in left pectoral position. No
pneumothorax.
Brief Hospital Course:
75 yo M with history of ischemic cardiomyopathy, recurrent
Vtach, atrial fibrillation, and PVD who p/w recurrent VT. He had
an unsuccessful VT ablation, and was started on quinidine and
mexilitine, w/ suppression of VT, prior to discharge.
# Vtach: The patient has a h/o Vtach and is s/p 2 ablations and
ICD placement previously. He presented with recurrent Vtach from
a scar focus with ICD firing and ATP pacing successful in
terminating VT. The patient was taken to the EP lab and
underwent ablation. In the PACU, he had an episode of Vtach,
either from irritation of the myocardium from the procedure
versus failed ablation. The patient was given lidocaine bolous
and started on lidocaine drip in the PACU. He was then sent to
the CCU for monitoring. He was started on mexilitine and recived
2 doses before the lidocaine gtt was stopped. He was monitored
on telemetry without event. The mexilitine was stopped the day
after the procedure. He returned to the floor, and had two
additional episodes of VT the following day. He was started on
quinidine and mexilitine prior to discharge. At the time of
discharge, he had been VT free for over 24 hours.
# PVD: The patient has PVD and has a R iliac artery stent from
previous admission. During the cath, a long sheath was used that
traversed the stent. This occluded the stent and caused
transient leg ischemia. Once the sheath was pulled, LE perfusion
returned. Pulses were monitored and at time of discharge were at
his normal baseline.
# A fib: Coumadin was continued for goal INR [**1-6**]. Home
metoprolol and digoxin were continued. Because of interaction
with quinidine, coumadin was restarted post-EP procedure at a
lower dose, and he will need an INR check 2-3 days
post-discharge.
# CAD: Continued statin, plavix, aspirin, lisinopril, and
metoprolol.
# Chronic Systolic CHF: Continue lisinopril, metoprolol, lasix.
Patient received 80mg IV lasix x 1 on arrival to CCU because
appeared volume overloaded. He responded well and was euvolemic
the next day.
# DM2: The patient's home insulin regimen was continued and he
was additionally covered with ISS.
# BPH: Continue flomax
Transitional Issues:
- Follow up on hospital thyroid studies - TSH elevated, but T4
normal suggesting subclinical hypothyroidism
- Follow up INR check 2-3 days post-discharge
- Follow up with EP scheduled for Friday.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY Start: In am
2. Clopidogrel 75 mg PO DAILY Start: In am
3. Metoprolol Tartrate 100 mg PO BID
Hold for SBP < 95 or HR < 65
4. Furosemide 80 mg PO DAILY Start: In am
Hold for SBP < 100
5. Lisinopril 10 mg PO DAILY Start: In am
Hold for SBP < 95
6. Digoxin 0.125 mg PO 4X/WEEK (MO,WE,FR,SA) Start: In am
7. Ranitidine 150 mg PO BID
8. Tamsulosin 0.4 mg PO HS
9. Atorvastatin 80 mg PO DAILY Start: In am
10. 70/30 22 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 80 mg PO DAILY
Hold for SBP < 100
5. 70/30 22 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Ranitidine 150 mg PO BID
7. Tamsulosin 0.4 mg PO HS
8. Outpatient Lab Work
Please get INR checked on Tuesday, [**9-12**] and Friday [**9-15**]
9. quiniDINE Gluconate E.R. 324 mg PO Q12H
RX *quinidine gluconate 324 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
10. Digoxin 0.0625 mg PO 4X/WEEK (MO,WE,FR,SA)
RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth 4x/week
Disp #*10 Tablet Refills:*0
11. Lisinopril 10 mg PO DAILY
Hold for SBP < 95
12. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Mexiletine 150 mg PO Q12H
RX *mexiletine 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 57523**],
It was a pleasure taking care of you at [**Hospital1 827**]. You came in after your ICD went off several
times for a heart arrhythmia called ventricular tachycardia.
While in the hospital, you received a VT ablation procedure. You
were also started on 2 anti-arrhythmic medications. Please
continue to take these medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2946**] A
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 57526**], [**Location (un) **],[**Numeric Identifier 14085**]
Phone: [**Telephone/Fax (1) 40106**]
*Please call your primary care provider to book [**Name Initial (PRE) **] follow up
appointment for your hospitalization. You need to be seen within
1 week of discharge.
We are working on a follow up appointment for your
hospitalization with Dr. [**Last Name (STitle) **] [**Name (STitle) **]. It is recommended you be
seen within 2 weeks of discharge. The office will contact you at
home with an appointment. If you have not heard within 2
business days please call the office [**Telephone/Fax (1) 62**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
ICD9 Codes: 4271, 4280, 2724, 412 | [
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train_18377 | completed | cf048fb3-666c-4b67-9fea-ec44f6d91215 | Medical Text: Admission Date: [**2171-2-4**] Discharge Date: [**2171-2-14**]
Date of Birth: [**2096-2-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
epigastric pain radiating to back
Major Surgical or Invasive Procedure:
[**2-4**] Endovascular stent graft of descending thoracic aorta.
History of Present Illness:
75 yo F s/p Ascending aorta and hemiarch replacement and
resuspension of AV in [**4-27**]. Presented to ED on [**2-3**] with
epigastric pain radiating to the back and N/V. CTA showed
penetrating ulcer of descending thoracic aorta, size of aorta at
level of ulcer 5.7 cm and muralthrombus from level of ulcer to
celiac trunk.
Past Medical History:
1. Aneurysm of ascending aorta and aortic arch, s/p repair [**2168**]
2. Tortuous dilated thoracic aorta.
3. HOCM- LVOT 10mmHg cath [**2168**], [**2169**] TTE: LVOT 19mmHg, 1+AR,
1+MR
4. H/o Dysphagia with aneurysm
5. L vocal cord dysphagia- [**2168**]
6. Hypertension.
7. Hypercholesterolemia.
8. Diabetes mellitus, type 2.
9. Hypothyroidism.
10. Glaucoma.
11. Osteoarthritis.
12. Osteopenia
13. Status post total abdominal hysterectomy.
14. Status post colonic polypectomy.
15. h/o Left Nasolabial abscess ([**6-/2170**])
Social History:
H/o mild tobacco, quit [**2161**]. No ETOH/drugs. Lives alone, does
own shopping, ADLs.
Family History:
Father deceased cancer, mother died in childbirth.
Physical Exam:
Elderly F in NAD
98.2 68 132/80 18 97% on 2L
Lungs CTAB
CV RRR without M/R/G
Abdomen soft/NT/ND
Extrem without C/C/E, pulses 2+ t/o
Neuro grossly intact
Pertinent Results:
[**2171-2-14**] 05:25AM BLOOD WBC-9.6 RBC-3.79* Hgb-10.8* Hct-32.2*
MCV-85 MCH-28.6 MCHC-33.7 RDW-15.8* Plt Ct-313
[**2171-2-3**] 09:30PM BLOOD WBC-8.4# RBC-5.20 Hgb-14.9 Hct-41.2
MCV-79* MCH-28.5 MCHC-36.1* RDW-16.1* Plt Ct-219
[**2171-2-14**] 05:25AM BLOOD Plt Ct-313
[**2171-2-12**] 01:45AM BLOOD PT-15.6* PTT-29.7 INR(PT)-1.4*
[**2171-2-3**] 09:30PM BLOOD Plt Ct-219
[**2171-2-14**] 05:25AM BLOOD Glucose-48* UreaN-11 Creat-0.6 Na-142
K-3.9 Cl-104 HCO3-34* AnGap-8
[**2171-2-3**] 09:30PM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-140
K-3.7 Cl-101 HCO3-30 AnGap-13
[**2171-2-11**] 02:05AM BLOOD ALT-17 AST-19 LD(LDH)-256* CK(CPK)-85
AlkPhos-65 Amylase-55 TotBili-0.8
CHEST (PORTABLE AP) [**2171-2-12**] 5:34 PM
CHEST (PORTABLE AP)
Reason: eval edema, effusions
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p TAAA stent
REASON FOR THIS EXAMINATION:
eval edema, effusions
HISTORY: Status post AAA stent.
FINDINGS: In comparison with the study of [**2-4**], there is no
change in the appearance of the heart and lungs. Mild blunting
of the left costophrenic angle is suggested. Endotracheal tube
and central catheter have been removed.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2171-2-8**] 10:39 AM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
Reason: eval hematoma in pt with slowly dropping Hct
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p descending aortic stent graft placement
REASON FOR THIS EXAMINATION:
eval hematoma in pt with slowly dropping Hct
CONTRAINDICATIONS for IV CONTRAST: None.
CTA OF THE CHEST
CLINICAL HISTORY: 75-year-old woman, status post descending
aortic stent graft replacement with retroperitoneal hematoma and
slowly dropping hematocrit.
TECHNIQUE: MDCT-acquired axial images were initially obtained
through the chest and abdomen without contrast, followed by
contrast-enhanced images through the chest, abdomen, and pelvis
after administration of 100 cc of intravenous Optiray.
COMPARISON: [**2171-2-7**].
FINDINGS:
CT OF THE CHEST:
There is marked diffuse enlargement of the thyroid gland,
particularly the left thyroid lobe, most compatible with
multinodular goiter.
Surgical clips are present in the anterior mediastinum. The
previously noted graft in the ascending aorta is stable in
appearance. The ascending aorta measures 3.9 x 4.0 cm at the
level of the main pulmonary artery. The previously noted stent
graft extending from the aortic arch into the proximal abdominal
aorta is stable in appearance. There is a persistent crescentic
pooling of contrast along the medial aspect of the stent
compatible with an endoleak. This is not significantly changed
from the prior examination. There is no mediastinal hematoma.
The previously noted small left pleural effusion has resolved.
The lungs are clear with the exception of several small
scattered areas of subsegmental plate-like atelectasis.
CT OF THE ABDOMEN:
The liver is normal in size and contour. High-density material
is seen in the gallbladder compatible with vicarious excretion
of the contrast. The spleen, pancreas, adrenal glands, and
kidneys are unchanged. A simple renal cyst is again noted in the
left kidney measuring approximately 3.6 cm in greatest
dimension.
The celiac and superior mesenteric arteries are patent. The
small and large bowel are normal in caliber.
The previously noted right retroperitoneal hematoma has
increased in size and now measures 8.8 cm in transverse, 9.1 cm
in AP, and 18 cm in craniocaudal dimension. Additionally,
multiple hyperdense components are now identified within the
hematoma suggestive of rebleeding. A small component of the
hematoma is extending medially as before to the region of the
right common iliac pseudoaneurysm. However, no active contrast
extravasation is identified in this region.
The previously identified pseudoaneurysm which arises at the
level of the bifurcation of the right common iliac artery and
right external iliac artery is unchanged in appearance and
measures approximately 1.3 cm in diameter.
The external and internal iliac arteries are patent bilaterally.
There has been slight interval decrease in subcutaneous
emphysema along the right anterior abdominal wall. Midline
surgical staples are again noted. There is asymmetric thickening
of the right rectus abdominis muscle and somewhat increased
attenuation likely reflecting an intramuscular hematoma in this
region.
CT OF THE PELVIS:
The urinary bladder is unremarkable. There is no significant
free pelvic fluid.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Interval increase in the size of the right retroperitoneal
hematoma which now also contains new hyperdense components
suggestive of more accute hemorrhage. Since no precontrast
images are availble through the region of hematoma,evaluation
for active contrast extravasation cannot be accurately done.
2. Intramuscular hematoma involving the right rectus abdominis
muscle, probably minimall increase since the prior study.
3. No significant change in appearance of the thoracic stent
graft and previously noted endoleak. No evidence of mediastinal
hematoma.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] A [**Hospital1 18**] [**Numeric Identifier 27498**] (Complete)
Done [**2171-2-4**] at 4:04:15 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2097-3-4**]
Age (years): 73 F Hgt (in): 66
BP (mm Hg): 154/84 Wgt (lb): 157
HR (bpm): 53 BSA (m2): 1.81 m2
Indication: Intra-op TEE for Thoracic aortic stent
ICD-9 Codes: 440.0, 441.2, 424.1
Test Information
Date/Time: [**2171-2-4**] at 16:04 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW210-0:0 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Descending Thoracic: *4.2 cm <= 2.5 cm
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in aortic arch. Moderately dilated
descending aorta
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of mitral valve chordae. Calcified tips of papillary
muscles. Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch. The
descending thoracic aorta is moderately dilated with noted
intramural hematoma. There is an ulceration in the descending
thoracic aorta.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits).
Brief Hospital Course:
She was admitted to the cardiac surgery ICU and started on a
labetalol drip. She complained of pain despite blood pressure
control and was taken to the operating room on [**2-4**] where she
underwent placement of an endovascular stent graft of the
descending thoracic aorta. She was transferred to the ICU in
stable condition. She was extubated on POD #1. She was
transferred to the floor on POD #2. Ct scan showed large
retroperitoneal bleed and Type 2 endoleak. Her HCT was 22 and
she was transfused. Repeat CTA showed increase in size of RP
hematoma with ? of active hemorrhage. She was transferred back
to the ICU. She remained in the ICU for frequent hematacrit
checks. She remained stable and was transferred back to the
floor. She developed an ileus, however her nausea improved, she
is moving her bowels and tolerating a diet. She was ready for
discharge home on POD #10.
Medications on Admission:
Levoxyl 50', Glipizide 5', Latanoprost 0.005'. Pilocarpine 0.5 2
gtts TID, Dorzolamide-Timolol 2-0.5", Vasotec 30'
Discharge Medications:
1. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Pilocarpine HCl 0.5 % Drops Sig: Two (2) Drop Ophthalmic Q8H
(every 8 hours).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
penetrating ulcer in the descending thoracic aorta s/p aortic
stent graft
retroperitoneal bleed
PMH: HTN, s/p asc. aorta hemiarch replacement with resuspension
of AV [**2168**], ^chol., dysphagia, NIDDM, hypothyriodism, glaucoma,
OA, osteopenia, s/p TAH s/p colonic polypectomy, s/p I+D of
nasal abcess
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No driving while taking pain medicine.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks/Dr. [**Last Name (STitle) **] 4 weeks with CTA Torso
Completed by:[**2171-2-14**]
ICD9 Codes: 4019, 2859 | [
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train_18398 | completed | f2ab593e-45a9-4ee9-902a-0766b49b2217 | Medical Text: Admission Date: [**2108-11-3**] Discharge Date: [**2108-11-19**]
Date of Birth: [**2041-8-12**] Sex: M
Service: MEDICINE
Allergies:
Naprosyn
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
abd pain and hematuria
Major Surgical or Invasive Procedure:
intubation
ERCP
History of Present Illness:
67 yo man with CLL found to have atypical lymphocytes at outside
hospital. Failed ERCP and MRCP for LFT's. Transfered here with
high LFT's low grade fever.
Past Medical History:
CLL
High Chol
HTN
Social History:
no tob
+ EtOH 7 beers per week
no IVDU
Family History:
CAD
MM
Physical Exam:
98.8 98 154/85 95%on 2L NC
sleepy
PERRL, icteric sclera
supple neck
CTAB
RRR occ ectopy, no murmur
abd obese distended
Ext- no c/c/e
Skin - vesicles diffusely over body consit with VZV
Pertinent Results:
[**2108-11-3**] 10:45PM GLUCOSE-105 UREA N-14 CREAT-0.6 SODIUM-122*
POTASSIUM-3.5 CHLORIDE-86* TOTAL CO2-28 ANION GAP-12
[**2108-11-3**] 10:45PM LIPASE-186*
[**2108-11-3**] 10:45PM ALT(SGPT)-666* AST(SGOT)-408* ALK PHOS-242*
AMYLASE-110* TOT BILI-7.3* DIR BILI-3.6* INDIR BIL-3.7
[**2108-11-3**] 10:45PM CALCIUM-7.7* PHOSPHATE-2.3* MAGNESIUM-1.9
[**2108-11-3**] 10:45PM HAPTOGLOB-46
[**2108-11-3**] 10:45PM TSH-2.1
[**2108-11-3**] 10:45PM NEUTS-10* BANDS-0 LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-85* METAS-0 MYELOS-0
[**2108-11-3**] 10:45PM WBC-49.8* RBC-4.92 HGB-15.7 HCT-41.8 MCV-85
MCH-31.9 MCHC-37.5* RDW-13.7
[**2108-11-3**] 10:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2108-11-3**] 10:45PM PLT SMR-VERY LOW PLT COUNT-60*
[**2108-11-3**] 10:45PM PT-12.9 PTT-28.9 INR(PT)-1.0
[**2108-11-3**] 10:45PM FIBRINOGE-301
Brief Hospital Course:
Resp Failure - required intubation wor worsening mental status
and failure to protect airway. Found to have inpaired
oxygenation. Asp pna vs ards. Mult sputums unremarcable for
organisms including AFB, fungi, and nocardia.
Fever - despite tx for zoster and resolution of his LFT;s pt
continued to spike fevers for his entire admission. All studies
including cx and CT did not reveal a secondary source.
SVT/Hemodynamic instability - possible infeciton of heart with
zoster. PT with many rhythms during stay including a-fib,
bigeminy, wide complex tach. Exacerbated by fevers.
Intermittent hypo and hyper tension. Amiodarone used with some
effect.
[**Name (NI) **] pt given 2 week course of acyclovir with resolution of
vesicles.
ARF - pt developed ATN likely due to hypotension.
Low Plt- ITP vs CLL = did not respond to single donor plts.
On [**11-18**] pt HR dropped below 100 and BP started to decrease <60
on max dose neosynephrine. Family decided not to add more
pressors. Priest called, pressors stopped and pt was extubated.
His HR trended down and he died. Time of death 11:35pm
[**2108-11-18**]. Family present, declined autopsy.
Medications on Admission:
leukeran
ci[rp
famotidine
folic acid
HCTZ
lopressor
oxycodone
prednisone
tylenol
dilaudid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
CLL
zoster
repiratory failure
hemodynamic instability
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 5185, 5845, 2761, 486, 4019 | [
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train_17526 | completed | 91a22947-1a95-46c4-a78a-e6bd4db97048 | Medical Text: Admission Date: [**2171-2-22**] Discharge Date: [**2171-2-28**]
Date of Birth: [**2104-9-18**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Demerol
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: Ms. [**Known lastname 94939**] is a 66 year old
right-handed woman who has a history of two prior strokes with
residual weakness (husband not sure which side) and trouble with
speech, multiple MI's, and thyroid disease, who was found lying
on the floor by her husband 30 minutes ago. She was last seen
normal at 3:30 p.m. when her husband observed her sitting up in
bed watching TV. Then at about 5 p.m. he heard a thump and
found
that she had fallen out of bed and was lying on her left side.
He thinks that she was trying to talk but says she wasn't
producing any sounds, and wasn't following any commands. EMS
arrived and found her to be nonverbal with left sided weakness.
She was then brought to the [**Hospital1 18**] ED. I was able to examine her
(as described below) immediately upon arrival, after which she
was intubated due to her somnolence.
Per her husband Ms. [**Known lastname 94939**] had strokes in [**9-24**] and [**1-25**], both
of
which were treated at the [**Hospital1 756**]. He is not sure where the
strokes were located, but thinks they were from clots and not
bleeding. She has residual weakness on one side (first he said
left, then right) and has trouble speaking, but can walk with a
cane at baseline. He notes that her function has been declining
lately but cannot say why. She does not take any medications
per
her own choice. She has no history of diabetes or hypertension.
Review of systems: No known recent systemic illness per her
husband.
Past Medical History:
Past Medical History:
- Strokes in [**9-24**] and [**1-25**] as above
- Per husband had [**3-24**] MI's total
- High cholesterol
- Thyroid problem
Social History:
Social History: Lives with her husband. Uses marijuana. No
tobacco/EtOH/other drug use.
Family History:
Family History: N/C
Physical Exam:
Examination:
T afebrile HR 93 BP 161/86 RR 18 Pulse Ox 100% on O2 NC
General appearance: Frail 66 year old woman lying in bed with
eyes closed, occasionally squirming with right arm and leg
HEENT: c-spine collar in place due to fall
CV: Regular rate and rhythm without murmurs, rubs or gallops. No
carotid bruits.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended, no hsm or masses
palpated
Extremities: no clubbing, cyanosis or edema
Mental Status: Eyes are closed, does not open them to voice or
noxious stimuli. Does not follow commands. Does not produce
any
sounds or attempt to speak. She does squirm with her right arm
and leg with sternal rub.
Cranial Nerves: Right pupil round and reactive 3>2, left round
and reactive 2.5>2. Right gaze preference, can get to midline
but not past (could not check with OCR due to C-spine collar).
Does not blink to threat on either side. There is no nystagmus.
She has R>L facial weakness. She would not open her mouth.
Motor System: Diffusely diminished muscle bulk. Tone is normal
on the right, flaccid on the left. She spontaneously moves the
right arm and leg, semi-purposefully, but has no movement of the
left arm and leg, even to noxious stimuli.
Reflexes: Deep tendon reflexes are 2+ and symmetric. Plantar
responses are extensor on the right, equivocal on the left. No
[**Doctor Last Name 937**].
Sensory: She neglects the left side completely, with her head
turned to the right. Localizes to noxious stimuli with right
arm/leg, does not seem to notice noxious stimuli on the left
(although the latter assessment was made difficult by the fact
that she was getting needle sticks on both the right and left
side simultaneously during my examination)
Coordination/Gait: Could not assess
Pertinent Results:
[**2171-2-22**] 05:30PM PT-12.3 PTT-24.1 INR(PT)-1.1
[**2171-2-22**] 05:30PM PLT COUNT-309
[**2171-2-22**] 05:30PM NEUTS-37.1* LYMPHS-50.3* MONOS-5.6 EOS-6.5*
BASOS-0.4
[**2171-2-22**] 05:30PM WBC-9.2 RBC-4.05* HGB-13.0 HCT-37.0 MCV-91
MCH-32.0 MCHC-35.0 RDW-13.6
[**2171-2-22**] 05:30PM CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-2.5
[**2171-2-22**] 05:30PM CK-MB-3 cTropnT-<0.01
Brief Hospital Course:
Patient admitted to ICU under Neurology Service because
intubated.
Neurology:Patient had MRI done on day of admission which showed
right MCA inferior division acute stroke. Concern for seizure
was less likely and Dialntin and EEG cancelled. Patient had a
full stroke work up which revealed triglycerides of >900,
cholesterol > 300 and TSH >100. She was started on gemfibrazole,
Synthroid, and Atorvastatin. She had a TTE which was negative
for LV dysfunction, thrombus, or vegestations. In terms of her
exam, she followed no commands, had no speech, was very agitated
despite propofol/fentanyl, did not blink to threat, had left
hemiparesis arm > leg. She was able to be weaned to CPAP but
extubation was not possible because of copius secretions and
lower lung collapse. She developed a ventilator associated
pneumonia and was started on Vancomycin and Zosyn. She was fed
via NG tube. Her daughter and proxy made the decison to make the
patient CMO as it was likely patient would need PEG and
tracheostomy in long term management. Palliative Care was
consulted and patient made CMO. She died on [**2171-2-28**].
Medications on Admission:
Patient not compliant on medication
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
stroke
Discharge Condition:
died
Discharge Instructions:
None
Followup Instructions:
None
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 486, 2720 | [
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train_16572 | completed | 79823763-84b3-40f8-a89e-c90f1b0f3801 | Medical Text: Admission Date: [**2158-2-17**] Discharge Date: [**2158-2-17**]
Date of Birth: [**2111-9-15**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p hanging, anoxic brain injury
Major Surgical or Invasive Procedure:
arterial line placement
History of Present Illness:
46F whose son committed suicide several years ago, attempted
suicide by hanging prior to presentation. She was found
unresponsive & EMS was called. She was resuscitated by CPR,
intubated & brought to the ED.
Past Medical History:
depression
Social History:
noncontrib
Family History:
son committed suicide
Physical Exam:
+pulse
GCS 3T
neck with anterior ecchymosis
RRR
CTA bilat
slight abdom distension
Pertinent Results:
refer to carevue
Brief Hospital Course:
[**2-16**]: GCS 3T on presentation to trauma bay. CT head confirmed
anoxic brain injury. Transferred to TSICU & NEOB notified.
[**2-17**]: Family meeting, where decision to wthdraw care & subseq.
donate organs. NEOB involved. Extubated, declared at 2047, &
transported to OR for organ harvest. Family notified.
Medications on Admission:
lexapro, vicodin, xanax
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p hanging
depression
anoxic brain injury
ischemic colitis
ischemic hepatitis
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2158-2-17**]
ICD9 Codes: 311 | [
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train_7006 | completed | ff07e546-3c36-42b0-8b18-230905769495 | Medical Text: Admission Date: [**2165-1-14**] Discharge Date: [**2165-1-21**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: This 74 year old, white male,
has a history of hypertension, hypercholesterolemia and
aortic stenosis and has been experiencing dyspnea and
occasional chest discomfort with walking. He underwent a
stress echo on [**9-8**] which revealed an ejection fraction of
55 to 60%; mild mitral regurgitation; trace tricuspid
regurgitation; mild aortic stenosis with an aortic valve area
of 1.9 cm squared and 2+ aortic insufficiency. His post
exercise echo showed
This report was CUT OFF!
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6516**]
MEDQUIST36
D: [**2165-1-21**] 04:38
T: [**2165-1-21**] 16:42
JOB#: [**Job Number 24411**]
ICD9 Codes: 4241, 4019, 2720 | [
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train_7554 | completed | eb1b29c3-477f-40b2-8323-fbc352aefc15 | Medical Text: Admission Date: [**2127-8-27**] Discharge Date: [**2127-8-29**]
Date of Birth: [**2073-3-2**] Sex: M
Service:
Th[**Last Name (STitle) 44544**]a 54-year-old male with a known mitral valve prolapse
since adolescence who developed significant regurgitation.
He was taken to the Operating Room on [**2127-8-27**] where a mitral
valve repair was done. The patient did well postoperatively
and was transferred to the CSRU. He was fully weaned from
his ventilator and extubated. He continued to improve.
Physical therapy was consulted for ambulation and he did well
postoperatively. The chest tube was removed. His Foley was
pulled and he was kept on A-pacing due to slow return of
sinus rhythm. He was transferred to the floor on
postoperative day #2. He continued to improve. His chest
tube was pulled. His Foley had been removed at midnight. He
improved and physical therapy came to see him. They
suggested for him to go home with full ambulation. His wires
were removed on postoperative day #2 and on postoperative day
#3, the patient was discharged home on stable condition. He
was given prescriptions for Percocet 1 to 2 tablets po q4h,
Zantac 150 po bid, Colace 100 po bid, KCL 20 milliequivalents
po bid, Lasix 20 mg po bid, Motrin 400 po q6h prn. The
patient is instructed to follow up in one to two weeks with
is primary care physician and four to six weeks with Dr. [**Last Name (Prefixes) 2545**]. The patient is discharged in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2127-8-29**] 10:36
T: [**2127-8-29**] 10:45
JOB#: [**Job Number 44545**]
ICD9 Codes: 4240, 4019, 2720 | [
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train_6434 | completed | 32d8cf58-0719-4fbc-90f0-1e7663cd70b2 | Medical Text: Admission Date: [**2156-6-17**] Discharge Date: [**2156-6-24**]
Date of Birth: [**2104-4-22**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Patient is 52-year-old gentleman
with slurred speech in the morning of admission in the
shower, then fell, and had a seizure witnessed by his wife.
Taken to an outside hospital. He is unresponsive,
decerebrate posturing, and intubated at the outside hospital.
Transferred to [**Hospital1 69**] for
further management.
Head CT scan shows large right frontal intracranial
hemorrhage.
PAST MEDICAL HISTORY: Hypertension.
PAST SURGICAL HISTORY: Unknown.
ALLERGIES: Patient has no known allergies.
MEDICATIONS: Aspirin.
PHYSICAL EXAMINATION: On physical exam, the patient was
intubated, unresponsive. Right pupil was fixed and dilated.
Left pupil was 3 mm and nonreactive. Patient's chest was
clear to auscultation. Cardiac: S1, S2, no murmurs, rubs,
or gallops. Abdomen is soft, nontender, nondistended,
positive bowel sounds. Extremities: Cool, positive pedal
pulses. Neurologic examination: No eye opening, pupils
right was fixed and nonreactive, 3 nonreactive, no corneals.
Bilateral decerebrate posturing in the upper with minimal
withdraw on the lowers.
Patient was taken immediately to the OR, where he underwent a
right frontal craniotomy for excision of hematoma, then
underwent a diagnostic arteriogram which showed a right MCA
aneurysm which was not treated.
Postoperative, his pupils were 3.5 mm bilaterally and
nonreactive. He was intubated with no sedation. He had weak
corneal on right and left side and there was flexure
posturing in the upper extremities bilaterally. Continued on
Dilantin. Had a repeat head CT scan, which showed
hydrocephalus and a vent drain was placed on [**2156-6-18**]. He
remained in the Intensive Care Unit with no change in his
mental status, decerebrate posturing. The family was
notified of his poor prognosis and poor outcome.
Patient was made comfort measures only and expired on
[**2156-6-24**]. Patient was referred to the Organ Bank for organ
donation, however, the patient did not progress to asystole
within the two hour period specified by the hospital policy,
and therefore organ donation was not carried out. Patient
expired on [**2156-6-24**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2156-9-6**] 11:12
T: [**2156-9-16**] 11:39
JOB#: [**Job Number 48141**]
ICD9 Codes: 431 | [
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train_9173 | completed | a2006a26-fbd9-4775-b387-44876ca4534c | Medical Text: Admission Date: [**2144-12-1**] Discharge Date: [**2144-12-12**]
Date of Birth: [**2062-9-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Shortness of Breath, Hypoxia
Major Surgical or Invasive Procedure:
Intubation
PEG replacement
History of Present Illness:
HPI: This is an 82 yo M with a past medical history of vascular
dementia, s/p CVA with aphasia and dysphagia requiring G-tube
[**12-26**] chronic aspiration, recurrent aspiration pneumonias, and h/o
hemoptysis, was brought to [**Hospital1 18**] after having worsened shortness
of breath and hypoxia at his NH. Apparently there is some
concern he was hypoxic for a while until his NH brought him in.
On the day of admission, he was noted at the NH to be short of
breath with sats in the 70's on room air. He was started on O2,
and was watched during the morning, but his status continued to
worsen and was transferred to our ED for further work up.
.
In the ED, he was placed on a NRB and sats came up to 98% but
respiratory rates continued in the 30's. He was noted to have
abdominal distention as well, and an NGT was placed with a lot
of air output. His breathing seemed to improve after
decompression. He was taken for chest and abdominal films which
seemed to be concerning for a right lower lobe infiltrate, and
he was given doses of cefepime, flagyl and levofloxacin. His
labs were significant for a normal wbc with 4 bands on diff
without a left shift, and a lactate of 1.6. His vitals before
transfer were temp of 101.6, RR 32, sats high 90's on NRB.
Without ABG's, the decision was made to intubate the patient
prior to transfer, out of concern that he was tiring out. Post
intubation he had a transient episode of bradycardia to the
40's. He was hemodynamically stable throughout. No
post-intubation ABG performed.
.
Past Medical History:
Renal/GU:
1. Nephrolithiasis/Uretolithiasis/Urosepsis
a.Proteus urosepsis secondary to obstructing uretal stone,
relieved by percutaneous nephrostomy tube, complicated by
perinephric hematoma. Hospitalized [**2141-3-29**] x14d.
b.Hematuria from nephrostomy secondary to renal stone.
Hospitalized [**2141-4-16**] x5d.
c.Tube dislodged [**2141-5-25**] and was replaced
d.Klebsiella urosepsis secondary to uretrolithiasis.
Hospitalized [**2141-8-7**] x2d
e.Uretal stone was passed during hospitalization [**2141-8-7**].
f. Percutaneous nephrostomy tube removed
CV:
1.Hypertension.
2.Descending thoracic aortic aneurysm.
GI:
1.G tube placement
2.Dysphagia secondary to CVA, plus aspiration pneumonia
status/precautions
3.Cholelithiasis
4. History of elevated liver function tests.
PULM:
1.Aspiration pneumonia. Hospitalized [**6-/2136**]
MSK:
1.S/p Proteus abscess. Hospitalized [**7-27**]. Status post incision
and drainage.
Neuro/Psych:
1.Cerebrovascular accident leading to dementia and aphasia.
Nonverbal.
2.Depression
3.Atypical Psychosis
FEN:
1.H/o of hypernatremia
Social History:
The patient is not verbal. He lives at [**Hospital3 2558**]. His
family is involved in his care.
Family History:
N/C
Physical Exam:
VS: Temp: 98 ax BP: 143/88 HR: 105 RR: 14 O2sat: 96% on
A/C 550 x 14 FiO2 1.0, peep 5
GEN: intubated and sedated, NAD
HEENT: PERRL, anicteric, MM dry, op without lesions. poor
dentition. NGT in place draining yellow fluid.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with moderate air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: distended, +b/s, soft, no masses, g-tube in place, site is
c/d/i. Flushes without resistance. Asymmetric distention, very
tympanitic to percussion.
EXT: no c/c/e, warm, good pulses (hands cool). Contractures
present
SKIN: no rashes/no jaundice
NEURO: unable to conduct adequate exam at this time. Could not
obtain DTR's. Increased tone. Mild peripheral wasting.
RECTAL: guaiac negative, [**Male First Name (un) 1658**] colored stool
Pertinent Results:
[**2144-12-1**] 11:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2144-12-1**] 11:24PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2144-12-1**] 11:24PM URINE RBC-70* WBC-26* BACTERIA-NONE YEAST-NONE
EPI-0
[**2144-12-1**] 11:24PM URINE MUCOUS-RARE
[**2144-12-1**] 10:08PM GLUCOSE-149* UREA N-27* CREAT-1.2 SODIUM-141
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
[**2144-12-1**] 10:08PM ALT(SGPT)-14 AST(SGOT)-27 LD(LDH)-246 ALK
PHOS-68 AMYLASE-76 TOT BILI-0.9
[**2144-12-1**] 10:08PM LIPASE-22
[**2144-12-1**] 10:08PM ALBUMIN-4.2 PHOSPHATE-3.8 MAGNESIUM-2.6
[**2144-12-1**] 10:08PM TSH-0.57
[**2144-12-1**] 10:08PM WBC-9.2 RBC-5.01 HGB-15.1 HCT-43.3 MCV-87
MCH-30.1 MCHC-34.8 RDW-14.0
[**2144-12-1**] 10:08PM PLT COUNT-158
[**2144-12-1**] 10:08PM PT-13.5* PTT-26.5 INR(PT)-1.2*
[**2144-12-1**] 09:44PM TYPE-ART PO2-244* PCO2-56* PH-7.34* TOTAL
CO2-32* BASE XS-3
[**2144-12-1**] 05:14PM LACTATE-1.6
[**2144-12-1**] 05:00PM GLUCOSE-159* UREA N-28* CREAT-1.3* SODIUM-139
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-30 ANION GAP-14
[**2144-12-1**] 05:00PM estGFR-Using this
[**2144-12-1**] 05:00PM proBNP-168
[**2144-12-1**] 05:00PM WBC-8.3 RBC-5.00 HGB-15.0# HCT-42.7# MCV-85#
MCH-30.0 MCHC-35.2* RDW-14.3
[**2144-12-1**] 05:00PM NEUTS-59 BANDS-4 LYMPHS-19 MONOS-11 EOS-2
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2144-12-1**] 05:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2144-12-1**] 05:00PM PLT SMR-NORMAL PLT COUNT-176
[**2144-12-1**] 05:00PM PT-12.9 PTT-27.3 INR(PT)-1.1
,,,,,,,,,,,,,,,,,,,,,,,,,,,
CT ABDOMEN PELVIS CHEST [**2144-12-2**]
.
CT OF THE CHEST: There is an endotracheal tube in place with its
tip approximately 3 cm above the carina. The nasogastric tube is
seen with its tip in the stomach. The heart is mildly enlarged.
Coronary artery calcifications are noted. Evaluation of the
pulmonary arteries demonstrates several filling defects within
the segmental and subsegmental branches of the left upper lobe
pulmonary artery consistent with pulmonary emboli. There is also
increase in caliber in the main left pulmonary artery that
measures approximately 3.1 cm. Pulmonary arteries, branches of
the right pulmonary artery and left lower lobe pulmonary artery
are unremarkable.
The tracheobronchial tree is patent. There is a mildly prominent
right hilar lymph node that measures 1.3 x 1.6 cm.
There is an aneurysm with an extensive partially calcified
thrombus involving the descending thoracic aorta that measures
approximately 4.7 x 3.5 cm. This is stable when compared with
the prior examination of [**2142-2-5**].
Evaluation of lung windows demonstrates bibasilar atelectasis.
There is diffuse mild emphysema. There is no pneumothorax and no
pleural effusions.
CT OF THE ABDOMEN: The liver is unremarkable. There is no
intrahepatic or extrahepatic biliary dilatation. Multiple
calcified gallstones are seen within the gallbladder. There is
no gallbladder wall thickening or pericholecystic fluid. The
pancreas demonstrates normal diffuse homogeneous enhancement. A
3-mm fat-containing lesion is seen in the tail of the pancreas
that is unchanged since the prior CT of the abdomen from [**2140**]
and likely represents a small lipoma. The spleen is normal in
size and contour. The left adrenal gland is unremarkable in size
and demonstrates several calcifications that are stable since
the prior study. There is diffuse enlargement of both medial and
lateral limbs of the right adrenal gland _____ have a lobular
appearance. This is also stable when compared with the prior CT
of the abdomen from [**2140**].
The kidneys enhance symmetrically. There is no hydronephrosis. A
very small subcapsular fluid collection is seen along the
posterior cortex of the right kidney likely reflecting residual
fluid from the previous hematoma that was seen on the prior
study. Multiple renal cysts are present. There is also an
indeterminate lesion measuring approximately 1.1 cm in the
medial aspect of the left kidney (hypoenhancing) that is
unchanged since the prior study from [**2140**].
Multiple areas of scarring and calcifications are seen in both
renal cortices. No pathologically enlarged intra-abdominal lymph
nodes are identified.
The small bowel is normal in caliber. Large amount of stool is
seen in the rectum compatible with rectal impaction. There is
gaseous distention of the proximal rectum and distal descending
colon. The proximal descending colon, transverse colon and the
right colon are unremarkable. There is no evidence of free air
or bowel pneumatosis. The small bowel is normal in caliber. The
abdominal aorta is normal in caliber and demonstrates diffuse
atherosclerotic calcifications. The celiac and superior
mesenteric arteries are patent.
CT OF THE PELVIS: There are bilateral fat-containing inguinal
hernias. There is a Foley catheter in place. The urinary bladder
is collapsed which limits its evaluation. There is no
significant free pelvic fluid. No pelvic masses or
pathologically enlarged pelvic lymph nodes are identified.
Rectal impaction is present as above.
Extensive bony productive changes are seen in the region of the
left ischium that are unchanged since the prior study.
Incidental note is made of a central filling defect in the right
common femoral vein (series 5, image 102) that may possibly
represent a deep venous thrombosis. Correlation with Doppler
ultrasound is recommended for further evaluation.
BONE WINDOWS: There is a compression fracture of superior
endplate of L1 that is unchanged since the prior study. No
suspicious lytic or sclerotic lesions are identified. There are
degenerative changes at L5-S1 level with disc space narrowing
and subchondral sclerosis.
IMPRESSION:
1. Pulmonary emboli involving segmental and subsegmental
branches of the left upper lobe pulmonary artery.
2. Emphysema.
3. Cardiomegaly and coronary artery calcifications.
4. Cholelithiasis.
5. Rectal impaction with likely secondary gaseous distention of
the proximal rectum and distal descending colon.
6. Probable deep venous thrombosis involving the right common
femoral vein. Further evaluation with Doppler ultrasound is
recommended for further evaluation if clinically indicated.
.
[**12-3**] CT NECK WITHOUT CONTRAST
.
HISTORY: Hypoxic respiratory failure, evaluate for laryngeal
edema.
An endotracheal tube is seen in place and there is collapse of
the larynx surrounding the endotracheal tube. As such,
evaluation of the laryngeal structures is not possible in an
intubated state. There does appear to be mild edema of the
subglottis which could be related to the process of intubation.
There is bilateral maxillary and ethmoid opacification. Small
maxillary sinus fluid levels are seen. The study is limited for
evaluation of lymphadenopathy although no large masses are
identified.
Evaluation of the brain parenchyma demonstrates volume loss.
There is bilateral pleural fluid/thickening.
IMPRESSION:
Endotracheal and NG tube are seen in situ and it is difficult to
assess for edema of the larynx in an intubated state.
.
[**12-3**] ECHOCARDIOGRAM.
.
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Suboptimal
technical quality, a focal LV wall motion abnormality cannot be
fully excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Aortic valve not well seen. No AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Prolonged (>250ms) transmitral E-wave decel time. LV inflow
pattern c/w impaired relaxation.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views. Suboptimal image quality -
ventilator.
Conclusions
Technically suboptimal study. The left atrium is normal in size.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%) Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
no aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. There
is no pericardial effusion.
Due to the technically suboptimal nature of this study, a
cardiac source of embolus cannot be excluded with certainty.
.
[**12-7**] CT HEAD WITHOUT CONTRAST
.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: The study is slightly
limited by patient movement. Allowing for this limitation, there
is no evidence of intra-or extra-axial hemorrhage, shift of
normally midline structures, mass effect or hydrocephalus. There
is prominence of the ventricles and sulci consistent with
moderate atrophy. Periventricular and subcortical white matter
hypodensity presumably represents chronic microvascular ischemic
change. No fractures are identified. There is confluent
opacification of the left frontal sinus, multiple ethmoid air
cells and the sphenoid sinus. There is moderate circumferential
thickening within the maxillary sinuses, left greater than
right. A nasogastric tube is noted in place. The mastoid air
cells are diminutive and opacified with soft tissue/fluid
density.
IMPRESSION:
1. Study limited by patient movement. No definite evidence for
intracranial hemorrhage or edema.
2. Moderate-to-severe confluent paranasal sinus opacification as
described above.
3. Significant brain atrophy with changes of chronic
microvascular ischemia
.
.
CONVERT G TO GJ, ALL INCL. [**2144-12-7**] 8:12 AM
.
OPERATORS: Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] performed the procedure.
Dr. [**Last Name (STitle) **], attending radiologist, was present throughout the
procedure.
PROCEDURE AND FINDINGS: After the risks, benefits and
alternatives of the procedure were explained to the patient's
wife written informed consent was obtained. A prepocedure
timeout was performed to confirm the patient's identifying
information.
The patient was placed supine on the angiographic table and the
abdomen and Foley catheter were prepped and draped in standard
sterile fashion. A 0.035 [**Doctor Last Name **] wire was advanced through the
Foley catheter into the duodenum under fluoroscopic guidance.
The indwelling Foley was removed over the wire and exchanged for
a 18-French peel-away sheath was advanced into the stomach. The
wire was exchanged for a 0.035 Amplatz stiff wire which was
advanced to the jejunum using a 5 French Kumpe catheter. The
Kumpe catheter was exchanged for a 16 French MIC
gastrojejunostomy tube which was advanced over the wire with the
tip in the distal duodenum under fluoroscopic guidance.
Injection of a small amount of contrast confirmed positioning.
The balloon was inflated with 10 cc of fluid to secure the
catheter. A sterile dressing was applied. The patient tolerated
the procedure well and there are no immediate procedure
complications.
Total fluoroscopy time : 7 minutes. A total of 20 cc of 60%
Optiray contrast was used.
IMPRESSION: Successful exchange of a Foley catheter for a 16
French MIC gastrojejunostomy feeding tube. The tip is in the
distal duodenum. The tube is ready to use.
.
EKG [**12-7**]
.
Baseline artifact. Sinus rhythm. Late R wave progression.
Compared to the
previous tracing of [**2144-12-4**] probably no significant change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
90 160 86 356/408 55 19 40
.
CXR [**2144-12-8**]
.
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with SOB, dysphagia, secretions, sounds wet
REASON FOR THIS EXAMINATION:
pulmonary edema
HISTORY: Shortness of breath with dysphagia and secretions.
FINDINGS: In comparison with the study of [**12-7**], allowing for the
slightly lower lung volumes, there is probably little overall
change. Mild atelectatic streaks are seen at the right base and
probably in the retrocardiac area as well. Tubes remain in
place.
Brief Hospital Course:
1)Pulmonary Embolus: The patient came to the ED very tachypneic
and hypoxic, as well as bloated. He was decompressed with an NG
tube. A CTA showed an embolism, and the patient was started on
anticoagulation with a heparin drip and bridged to warfarin.
Through the hospital course, he was intubated for persistent
hypoxia and tachypnea. An attempt at extubation was unsuccessful
because there was no cuff leak. There was concern for an upper
airway obstruction. CT of the neck showed only mild subglottic
edema. The patient has dysphagia post CVA and could not handle
his secretions. This, coupled with his lung congestion and
productive cough, made management of his secretions challenging.
He required constant deep suctioning by respiratory therapy in
order to prevent desat and keep him comfortable. A scopolamine
patch was used to control his oral secretions.
.
2)Aspiration pneumonia - for which he was started on vancomycin
and meropenem based on his prior cultures (he had been given
cefepime and levaquin previously in the ED, as well as flagyl).
All his blood and urine cultures remained negative. Stool
cultures were negative. C difficile was negative x 2. 3 days
prior to discharge, his IV antibiotics were stopped and he was
started on cefpodoxime, last day [**12-13**] as detailed in the
discharge paperwork.
.
3). DYSPHAGIA: He came with his PEG dislodged. This was pulled
and a Foley temporarily placed to maintain viability of the
tract. The patient then underwent successful PEG replacement by
IR. A previous consult by GI and images of the tract with
contrast revealed no problems, however GI recommended that the
procedure be done by IR due to the special kit required for the
tube's size. Prior to that exchange, the patient had been
receiving tube feeds via his NGT after decompression of his
bloated abdomen. Subsequently, the patient has been receiving
tube feeds via his PEG at 70 cc/hour and been followed by
nutrition. He needs to be propped up at all times when being
fed.
.
4). COMFORT CARE: The patient was admitted with fecal impaction,
contractures, and numerous pressure sores, as well as with
hypoxia, infection, and a malpositioned feeding tube. All of
these were addressed. The contractures seemed old but still he
had PT for stretching and evaluation. This raised questions
about the type of care he had been receiving, and case
management was informed for an investigation.
.
Prior to discharge, the patient is at baseline, on room air. We
have been restarting his blood pressure medications and
introduced few changes. These will need to be managed according
to his hemodynamics. He will need frequent lyte checks (he is on
hctz and potassium) as well as INR checks. Please see medication
list below.
.
The patient remains Full Code
Medications on Admission:
potassium 20meq daily
MVI
prilosec 20 daily
artificial tears
baclofen 10mg q6h
albuterol MDI
valium 1mg Qam, 2mg QHS
lactulose 30cc daily
lasix 20mg daily
HCTZ 12.5mg daily
lisinopril 20mg daily
tubefeeds
Discharge Medications:
1. Baclofen 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QID (4 times a
day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] Q24H (every 24 hours).
3. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily).
4. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
5. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
6. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
8. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day).
9. Scopolamine Base 1.5 mg Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q 72 HOURS ().
10. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Polyvinyl Alcohol 1.4 % Drops [**Last Name (STitle) **]: 1-2 Drops Ophthalmic Q4H
(every 4 hours).
12. Hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
13. Potassium Chloride 10 mEq Capsule, Sustained Release [**Last Name (STitle) **]:
One (1) Capsule, Sustained Release PO DAILY (Daily).
14. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY16 (Once
Daily at 16).
15. Cefpodoxime 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H (every
12 hours) for 2 days: Last dose [**2144-12-13**] pm.
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
17. Morphine 2 mg/mL Syringe [**Month/Day/Year **]: Two (2) mg Injection every [**2-28**]
hours as needed for pain, air hunger.
18. heparin drip to PTT 60-90 until INR 2
19. Valium 5 mg/mL Solution [**Month/Day (3) **]: One (1) mg Injection once a
day: In the morning.
20. Valium 5 mg/mL Solution [**Month/Day (3) **]: Two (2) mg Injection at
bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Pulmonary Embolism
Pneumonia
Dysphagia
Dementia
Fecal Impaction
Pressure sores (multiple)
Dehydration
Discharge Condition:
Stable. At baseline dementia and respiratory. Normal bowel
movements. No infection.
Discharge Instructions:
Admitted with shortness of breath and hypoxia and found to have
a pulmonary embolism, being treated with anticoagulation. His
PEG was malpositioned and it was replaced.
.
He also came impacted and had to be disimpacted manually. With
contractures and pressure sores. All of these issues are being
addressed. He is now at his baseline, on room air, comfortable,
but with deep dementia and requiring assistance for all his
ADLs.
.
It is important that the patient be turned in bed every two
hours, that he wears appropriate protection at his bony joints,
that he has his ulcers taken care of. He also needs daily
stretching of his limbs by PT. He is on tube feeds by PEG and
needs at least semi weekly labs/Chem 10 to ensure adequate
hydration. He also needs an adequate bowel program for him to
have a bowel movement at the very least every other day. He
needs his INR checked frequently until it is stabilized, and his
coumadin adjusted accordingly. He needs suctioning at an
adequate frequency because he cannot handle his secretions. He
needs to be propped up in bed at all times.
He needs mouth care and cannot have any nutrition or hydration
PO. His mouth must be swabed and hydrated at least every 4
hours.
.
Please return to the ED for any concerns.
Followup Instructions:
With facility doctor daily
Completed by:[**2144-12-12**]
ICD9 Codes: 5070, 5849, 4019 | [
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train_8221 | completed | 5c9ef2b6-dab5-4b6e-b04a-6382b45fe4ab | Medical Text: Admission Date: [**2201-4-21**] Discharge Date: [**2201-4-25**]
Date of Birth: [**2120-10-14**] Sex: M
Service: MEDICINE
Allergies:
Alprazolam / Hydrochlorothiazide / Sulfonamides / Iodine /
Clindamycin / Amoxicillin / Doxycycline / Cefaclor /
Erythromycin Base / Amiodarone / Levofloxacin
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
polymorphic VT
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
This is an 80 yo M hx nonischemic cardiomyopathy and cardiac
arrest w/AICD placement [**2194**], DM2 and Hypertension, recently
admitted for polymorphic VT in the setting of prolonged QT. At
that time he presented with dyspnea, conerning for infection,
was initially started on levofloxacin. He subsequently developed
polymorphic VT storm with ICD cluster shocks requiring generator
change, performed [**4-15**]. He was discharged on [**4-20**] after PM was
adjusted to HR 90, started on mixilotine after initially being
started on lidocaine drip, as well as started on verapamil and
changed from metoprolol to toprol.
Unfortunately the patient was unable to fill the rx for
mexilitine as it was not avaiable to pharmacy, had planned to
pick up this AM, was able to fill his other meds.
Pt left hospital yesterday, felt well. This AM he woke up at
4am, developed some mild substernal chest discomfort, [**5-7**],
non-radiating, no associated sx's. He called EMS and while being
transferred to ambulance, had recurrence of his ICD shocks.
Initially evaluated at OSH, where K was 3.5, repleted,
transferred to [**Hospital1 18**] for further care. He was seen on arrival to
CCU, feels well. He continue to have mild substernal chest
discomfort, [**4-6**], which he believes is heartburn, he has had
this discomfort for years, it is never exertional.
.
ROS: chest pain as per HPI, no further cough or dyspnea, no
orthopnea or PND, no recent fever, chills, lower extremity
edema, no diarrhea or dysuria. No known prior hx of MI.
Past Medical History:
1. As child, question big heart according to the father.
2. Hypertension.
3. Noninsulin dependent diabetes mellitus .
3. Hiatal hernia.
4. History of left bundle branch block.
5. Status post cardiac arrest [**2194**] with ICD placement at that
time.
6. Status post right epididymectomy in [**2163**] and right
inguinal hernia surgery in [**2163**].
8. [**2194-3-31**] echocardiogram with mild left atrial dilatation,
mild dilated left ventricular cavity, moderate to severe left
ventricular systolic dysfunction, delayed relaxation for
c/w left ventricular infiltrate, transaortic regurgitation.
9. CAD: On [**2194-3-31**], catheterization showed no significant
coronary
artery disease with hypokinesis of the anterior basal,
anterolateral, apical, inferior posterior basal walls with
ejection fraction of 25% to 30% and elevated LVEDP at 22.
10. VT/torsades in [**2194**] in setting of prolonged QTc (approx 70
shocks at that time)
Social History:
Married. Tobb 36yrs ago. 1 dtr. no etoh. R and D engineer, now
retired. Can walk 1 block.
Family History:
no early CAD
Physical Exam:
VS: T 98.8 BP 129/65, HR 95, RR 14, O2 sat 95% on RA
Gen: [**Last Name (un) 664**] obese, elderly male, in NAD
HEENT: MMM, JVP difficult to assess [**2-28**] body habitus
Cards: RRR nl S1S2 no MGR, PMI displaced laterally
Resp: slight ronchi at bases, no wheezes, good air entry.
Abd: BS+ NTND soft, no HSM
Ext: 2+ DP, PT b/l, no edema
Neuro: moving all 4 extremities
Skin: no rash
Pertinent Results:
[**2201-4-20**] 02:58AM BLOOD WBC-6.8 RBC-4.09* Hgb-12.4* Hct-35.7*
MCV-87 MCH-30.3 MCHC-34.8 RDW-13.4 Plt Ct-187
[**2201-4-25**] 07:31AM BLOOD WBC-10.3 RBC-4.81 Hgb-14.3 Hct-42.0
MCV-87 MCH-29.7 MCHC-34.0 RDW-13.8 Plt Ct-314
[**2201-4-20**] 02:58AM BLOOD PT-15.1* PTT-34.0 INR(PT)-1.3*
[**2201-4-22**] 03:11AM BLOOD PT-14.7* PTT-25.1 INR(PT)-1.3*
[**2201-4-20**] 02:58AM BLOOD Glucose-167* UreaN-31* Creat-1.0 Na-137
K-4.1 Cl-102 HCO3-30 AnGap-9
[**2201-4-25**] 07:31AM BLOOD Glucose-136* UreaN-32* Creat-1.4* Na-135
K-5.2* Cl-98 HCO3-29 AnGap-13
[**2201-4-20**] 02:58AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.2
[**2201-4-25**] 07:31AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.6
[**2201-4-21**] 12:40PM BLOOD TSH-2.7
[**2201-4-21**] 12:40PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2201-4-21**] 12:40PM BLOOD CK(CPK)-50
.
Cardiac Cath [**4-22**]
1. Coronary angiography of this left dominant system revealed no
significant coronary artery disease. The LMCA was short and had
no
angiographically-apparent coronary disease. The LAD was normal.
The LCX
was a large dominant vessel without obstructive coronary
disease. The
RCA was a small vessel and also was normal.
2. Resting hemodynamics revealed normal systemic arterial
pressure with
an SBP of 123 mm Hg. The LVEDP was elevated at 20 mm Hg
suggestive of
moderate diastolic dysfunction. There was no aortic stenosis on
left-heart pullback.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Moderate diastolic left ventricular dysfunction.
3. No aortic stenosis.
Brief Hospital Course:
Assessment: 80 yo M hx non-ischemic cardiomyopathy, HTN, recent
VT/torsades storm who returns with recurrence of torsades.
.
# VT/torsades: This appears to be related to prolonged QT. No
evidence of active ischemia and cath did not show evidence of
ischemic lesion.
QT continues to be prolonged, initially was attributed to
treatment with levaquin, although should have been out of
system. Other potential reasons for recurrence include
hypokalemia and missing mexilletine. K may have been somewhat
low in the setting of stress and catecholamine driven
intracellular shift. He was initially on lidocaine drip and
then transitioned to several antiarrhythmic regimens. Final
discharge regimen was mexillitine 200mg q8h, verapamil 240mg SR
(previously 120), and inderall LA 160mg
.
# Pump: nonischemic cardiomyopathy, EF 30-40%, appeared
euvolemic. Continued spironolactone, changed beta-blocker from
metoprolol to propranolol and started lisinopril 2.5mg daily
Medications on Admission:
Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Spironolactone 50mg daily
Toprol 150mg daily
Artificial Tears 1-2 DROP BOTH EYES PRN
Magnesium Oxide 400mg daily
Aspirin 325 mg PO DAILY
Pantoprazole 40mg daily
Metformin
Mexilitine 200mg q8hrs
Verapamil SR 120mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
7. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
10. Inderal LA 160 mg Capsule,Sustained Action 24 hr Sig: One
(1) Capsule,Sustained Action 24 hr PO once a day.
Disp:*30 Capsule,Sustained Action 24 hr(s)* Refills:*2*
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Outpatient Lab Work
Monday [**2201-4-27**]:
sodium, potassium, chloride, bicarb, BUN, creatinine, glucose,
calcium, magnesium, phosphate.
.
Please [**Month/Day/Year **] to his primary care provider, [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 488**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]:
[**Telephone/Fax (1) 8719**], Phone: [**Telephone/Fax (1) 8725**]
Discharge Disposition:
Home
Discharge Diagnosis:
Long QT syndrome
Ventricular Tachycardia / Torsades de points
chronic systolic heart failure
diabetes mellitus type II
Discharge Condition:
Good, no further ventricular arrhythmias.
Discharge Instructions:
You were admitted for an arrhythmia which caused your
defibrillator to fire. This was most likely due to not having
one of your antiarrhythmic drugs available. When put on this
medication, mexilitine, your rhythm improved. We also changed
some of your medications including verapamil, propranolol, and
magnesium to help prevent arrhythmias. You had a cardiac
catheterization procedure which showed no disease in the heart
arteries which would contribute to your arrhythmias.
.
For your heart function, we started a low dose of lisinopril
which helps prevent progression of heart failure.
.
For your heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1L
.
We initially increased your spironolactone to 75mg (three 25mg
tablets) daily, but your potassium increased and your kidney
function worsened slightly on the day of your discharge, so we
are asking you to decrease the spironolactone back down to 50mg
(two 25mg tablets) daily.
.
Because of this, you are also being given a prescription to get
lab work done on Monday [**2201-4-27**]. It is very important for you
to get this done to make sure that your electrolytes are at
appropriate levels. You can have this done at your primary care
physicians office or any local lab. Your results should be
faxed to your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], if you do not
get them drawn at his office.
.
Please take all your medications as prescribed. If you are
unable to take your medications, please call your primary care
physician or your cardiologist. Please seek medical attention
if you experience recurrent firing of your defibrillator, chest
pain, shortness of breath, or any other new or concerning
symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2201-4-28**] 12:20
.
Please also follow-up in Dr. [**Last Name (STitle) 34490**] device clinic. You can
discuss this in your appointment with him on [**2201-4-28**].
.
Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for
lab work on Monday as described above. Please also make an
appointment with him for sometime in the next 7 days. His
number is [**Telephone/Fax (1) 8725**].
.
Please follow-up with [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], cardiology, in the next
month. His number is Phone: [**Telephone/Fax (1) 8725**].
ICD9 Codes: 4271, 4254, 4280, 4019 | [
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train_8402 | completed | 52b228ba-043e-4deb-89bb-ede459c751aa | Medical Text: Admission Date: [**2120-11-8**] Discharge Date: [**2120-11-12**]
Date of Birth: [**2036-9-12**] Sex: F
Service: MEDICINE
Allergies:
Lactose Intolerance
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
nasogastric tube placement, foley catheter placement (both
removed prior to discharge)
History of Present Illness:
Per MICU: "84 yo F w/ Hx of dementia, Hx of GIB, p/w UGIB at
[**Hospital1 1501**]. NG lavaged in ED cleared after 750cc, GI does not want to
scope given comorbidities. Also noted to have fever to 101.4 and
U/A was positive so started on CTX in ED. Got CTA for mesenteric
ischemia w/ and w/o contrast which was negative. Rectal exam
guiac + but not grossly positive. Trop 0.04, EKG baseline:
Sinus, small depressions V4-V6. Has been HD stable. Complains of
abd pain. mental status is at baseline per son. In the ED,
initial VS: 97.6 108 172/87 16 97. Pt got 3LIVF and hct dropped
from 40->37. Started on IV pantoprazole and a foley and NGT
placed and pt admitted to MICU for ? emergent EGD."
.
In MICU pt was seen by GI who felt pt was not a candidate for
EGD given comorbidities unless she was to become hemodynamically
unstable. Son is HCP and he agreed with no EGD. MICU team also
discussed code status c son and he felt firmly that pt should be
FC (though was dnr/dni several admissions ago in [**12-15**]). Pt did
not have any further vomiting. Pt had one run of svt treated
with 5 metop IV x1. Pt was continued on ceftriaxone for her UTI.
Past Medical History:
Alzheimers
Diverticulosis (LGIB)
IDDM, c/b diabetic nephropathy and neuropathy w/ some balance
problems
HTN
[**Name2 (NI) **]
s/p TAH/BSO
s/p cholecystectomy
Lt humerus Fx [**2117**]
shoulder tendonitis
s/p breast cyst surgery
osteoarthritis of knees
L eye cataract repair
SVT in micu, paroxysmal afib
Social History:
Patient currently living at [**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **], a [**Location (un) 169**] [**Hospital1 1501**],
where she has been for over the past year. Her only living
family is her son [**Name (NI) **]. She is in the [**Hospital1 1501**] because of court
ordered protective services. She currently is unable to walk, or
carry out any ADL's. Smoking, drinking, and drug history unable
to be elicited.
Family History:
Signficant for Alzheimer dementia : her father, sister. [**Name (NI) **]
mother died of bone cancer.
Physical Exam:
Vitals - 98.7 143/79 105 18 100%RA
GENERAL: Mumbling incoherently, responds, but does not follow
commands.
HEENT: No elevated JVP. No scleral icterus. MM dry
CARDIAC: RRR, No MRG
LUNG: CTA anteriorly
ABDOMEN: Soft, NT, ND, BS+
EXT: 2+ pitting edema in L leg, L leg contracted
NEURO: Unable to perform neuro exam, pt. moving all extremities
spontaneously.
DERM: No rashes
Pertinent Results:
Admission labs:
[**2120-11-8**] 09:25AM BLOOD WBC-8.6 RBC-4.52# Hgb-13.2# Hct-40.8#
MCV-90 MCH-29.2 MCHC-32.4 RDW-15.4 Plt Ct-153
[**2120-11-8**] 09:25AM BLOOD Neuts-88.0* Lymphs-9.1* Monos-2.7 Eos-0.2
Baso-0.1
[**2120-11-8**] 09:25AM BLOOD PT-12.8 PTT-27.5 INR(PT)-1.1
[**2120-11-8**] 09:25AM BLOOD Glucose-314* UreaN-18 Creat-1.0 Na-138
K-8.2* Cl-104 HCO3-22 AnGap-20
[**2120-11-8**] 09:25AM BLOOD ALT-9 AST-54* LD(LDH)-1123*(hemolyzed,
wnl on repeat) CK(CPK)-206* AlkPhos-73 TotBili-0.4
[**2120-11-8**] 09:25AM BLOOD Lipase-26
[**2120-11-8**] 09:25AM BLOOD CK-MB-4
[**2120-11-8**] 09:25AM BLOOD cTropnT-0.04*
[**2120-11-8**] 07:30PM BLOOD CK-MB-5 cTropnT-0.05*
[**2120-11-8**] 11:57PM BLOOD CK-MB-6 cTropnT-0.05*
[**2120-11-8**] 09:25AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1
[**2120-11-8**] 09:39AM BLOOD Lactate-2.5*
[**2120-11-10**] 03:32PM BLOOD Lactate-1.4
Discharge labs:
[**2120-11-12**] 07:40AM BLOOD WBC-5.4 RBC-3.50* Hgb-10.3* Hct-31.3*
MCV-89 MCH-29.4 MCHC-32.9 RDW-15.6* Plt Ct-131*
[**2120-11-12**] 07:40AM BLOOD Plt Ct-131*
[**2120-11-12**] 07:40AM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-144
K-4.1 Cl114* HCO3-26 AnGap-8
[**2120-11-12**] 07:40AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9 Cholest-PND
[**2120-11-8**] CTA abd/pelvis: IMPRESSION:
1. Mild wall thickening involving the rectosigmoid junction and
rectum,
compatible with mild proctocolitis, which is either inflammatory
or infectious in etiology. Clinical correlation with endoscopy
is recommended.
2. Patent mesenteric arteries with diffuse atherosclerotic
disease within the celiac artery, SMA artery,and bilateral renal
arteries without significant stenosis.
3. Bilateral renal cysts, stable in size and appearance when
compared to
prior study.
4. Two enhancing lesions in the liver, one seen on the arterial
phase, and
the other in the portal venous phase. These were not seen
previously, and may represent perfusion anomalies. If clinically
indicated, an MR can be obtained for further evaluation.
[**2120-11-9**] LENI L leg: IMPRESSION: Limited study due to portable
technique and decreased diameter of the left lower extremity
veins as described above. However, no definite evidence of left
lower extremity deep venous thrombosis.
URINE CULTURE (Final [**2120-11-10**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
# UGIB: Appeared stable in ED and on the floor though she did
initially have coffee grounds in the ED which cleared from NG
lavage after 750cc. GI was consulted and recommended no EGD as
pt hemodynamically stable. It was felt that risks outweighed the
benefits. She was started on PPI [**Hospital1 **] and her diet advanced back
to her home diet (purees and nectar thick liquids).
.
#UTI: Lactate initially elevated but wnl after fluid repletion.
Pt was treated with ceftriaxone while inpatient and transitioned
to cefpodoxime to complete a 7 day course.
.
# Severe dementia: Remained near baseline per pt's son. She
makes eye contact but does not respond to questions
appropriately and does not know her name. She was continued on
depakote and risperdal.
.
# tachycardia/lateral 1mm ST depressions on EKG (variable
throughout admission) and small troponin bump: Trop felt to be
most likely secondary to small amount of demand given
tachycardia. Pt was ruled out for MI with 3 sets of cardiac
enzymes which did not show a rising troponin. Pt was started on
low dose metoprolol. A recent echo showed preserved EF so ace
not started (pt not hypertensive). Aspirin was deferred as pt
admitted for GIB. Sinus tachycardia resolved with fluid
repletion. Pt was continued on simvastatin.
.
# ? paroxysmal atrial fibrillation: pt carries this diagnosis
per paperwork from [**Hospital1 **]. Did have one brief episode of SVT
~100bpm on telemetry which resolved spontaneously. Metoprolol
12.[**4-9**] help with rate control during these episodes.
.
# DMI: Pt's NPH decreased to 11U and humalog sliding scale
started. She required minimal sliding scale.
.
# CONTACT/HCP: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 25703**]. Communication was
maintained c son throughout admission, though he was unable to
come in [**1-8**] recent rib injury.
Medications on Admission:
Purreed diet
Colace 100mg [**Hospital1 **]
CaCO3 500mg [**Hospital1 **]
Vitamin D 50k unitsQW
Risperdal 0.25mg [**Hospital1 **]
Depakote 250mg [**Hospital1 **]
Simvastatin 10mg QHS
NPH 22U sc qam
RISS [**Hospital1 **]: 200-250 4U, 250-300 6U, 300-350 8U, 351-400 10U
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection three times a day: please continue if pt unable to
ambulate. IF continued, NEED to check PTT and platelets to
confirm no rise in PTT and no drop in platelets twice weekly.
NEXT CHECK ON [**2120-11-13**]! If PTT rising or plts dropping MUST [**Name8 (MD) **]
MD as pt may require adjustment in dose or perhaps require a
test for heparin induced thrombocytopenia.
2. Simvastatin 10 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO DAILY
(Daily).
3. Risperidone 0.25 mg Tablet [**Name8 (MD) **]: One (1) Tablet PO BID (2
times a day).
4. Calcium Carbonate 500 mg Tablet, Chewable [**Name8 (MD) **]: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Divalproex 125 mg Capsule, Sprinkle [**Name8 (MD) **]: Two (2) Capsule,
Sprinkle PO BID (2 times a day).
6. Metoprolol Tartrate 25 mg Tablet [**Name8 (MD) **]: 0.5 Tablet PO BID (2
times a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Cefpodoxime 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day
for 6 doses.
9. Colace 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day.
10. Vitamin D 50,000 unit Capsule [**Last Name (STitle) **]: One (1) Capsule PO once a
week.
11. NPH Insulin Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: Eleven
(11) units Subcutaneous qam: titrate up as indicated.
12. Humalog 100 unit/mL Cartridge [**Last Name (STitle) **]: One (1) Subcutaneous
three times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
UTI, Upper GI Bleed
Discharge Condition:
able to speak and eat, not oriented to person, place or time.
Discharge Instructions:
Ms [**Known lastname **] was admitted to the hospital for upper GI bleed noted
at her nsg home. She was found to have coffee grounds by GI
lavage in the ED that cleared in the ED. She was admitted to the
MICU and had no further bleeding and was transferred to the
floor. GI was consulted but felt that pt would be a poor EGD
candidate. She was also found to have a UTI, for which she was
treated with ceftriaxone and then transitioned to cefpodoxime to
complete 7 day course. She was noted to have left>R lower
extremity swelling, but no DVT was found on ultrasound. She was
also noted to be very dehydrated and was treated with IV fluids
on day 1 and 2 of hospitalization. On day 3 she was able to
drink enough fluids (~1 liter). Her NPH was decreased from 22
qam to 11 qam as she had several low blood sugars. She was
initially not eating, and recieved IVF, but on HD 3 began
eating full pureed meals. She was also noted to have a small
troponin leak but ruled out for MI and was started on low dose
metoprolol [**Hospital1 **]. Pt was observed overnight and was stable.
Medication changes:
1. NPH decreased from 22U to 11U. This may need to be uptitrated
as she continues to eat more.
2. pt was started on metoprolol
3. she was started on UTI treatment with ceftriaxone and should
finish 7 day course with cefpodoxime at skilled nsg facility
4. added lansoprazole [**Hospital1 **]
Followup Instructions:
-Please monitor her vital signs and call physician for HR <60 or
>100, SBP >160 or <90, RR >20 or <12, oxygen saturation <93%.
-Please monitor for signs of UTI by follow up UA in 1 week as pt
is poor historian, as pt has had multiple prior UTIs.
-Please continue her diet and aggressive PO fluids as pt
appeared very dry on admission.
Completed by:[**2120-11-12**]
ICD9 Codes: 5789, 5990, 3572, 4019, 2720 | [
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train_8437 | completed | 1785bf87-97cd-4486-9c33-1accbfa1f62e | Medical Text: Admission Date: [**2156-1-11**] Discharge Date: [**2156-1-30**]
Date of Birth: [**2097-4-1**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
v tach arrest
Major Surgical or Invasive Procedure:
cardiac cath, stent placement
EP study
central line placement
intubation
extubation
intubation
History of Present Illness:
58 yo with PMH morbid obesity ?CMP w/ EF 40-45%, afib/flutter on
amio at home, COPD, OSA, IDDM, tonsillar CA s/p chemo/XRT [**12-22**]
with PEG. He was feeling generally well in his USOH and was
witnessed falling to his bathroom floor in AM [**1-9**]. His son
performed CPR until EMS arrived and found him in VF arrest
(down-time <5 min). He was intubated in the field was converted
out of VF with 1 shock, then transported to [**Hospital6 **]
where he was given lidocaine 100mg x 1 in the ED and started on
amiodarone drip.
.
His cardiac enzymes were negative and his electrolytes were not
derranged; His other labs were simply notable for a low hct of
27.1.
.
[**1-10**] midnight he was found to be in Vtach and was defibrillated
x 3 "with transient response;" he was kept on amiodarone drip.
He again went into pulseless VT and CPR was performed; he
received lidocaine 100mg x 1 with good response; he was then
started on lido drip at 2mg. He then had another VT event which
was resolved by repeat lidocaine bolus and increasing drip to
3mg. The lidocaine drip was stopped today as per EP
recommendations.
.
As per verbal report (not seen in notes) He has gone into
sustained monomorphic VT 6 times with 2 episodes converting to
VF; he was successfully defibrillated out of VF x 2. He was
cardioverted out of VT x 4. He is transferred here for further
management.
Past Medical History:
#HTN
# dilated CMP with EF 40-45% in setting of AFib; last EF 60%
# atrial fibrillation s/p cardioversion in [**2151**] and [**2153**]
# 1st degree AV block; symptomatic bradycardia on atenolol
# tonsillar CA s/p 3x cisplatin and XRT (finished [**12-22**])
# peripheral neuropathy
# diabetes type 2 non-insulin-dependent; c/b peripheral
neuropathy and toe amputations; chronic venous insufficiency
with chronic LE cellulitis
# recent tonsillar CA ?currently undergoing chemo/XRT?
# COPD/asthma (FEV1 72% pred),
# obstructive sleep apnea on BiPAP,
# gastroesophageal reflux and peptic ulcer disease causing GIB
# dyslipidemia,
# history of colonic polyps,
# iron deficiency anemia; ?AoCDz?
# CRI baseline Cr 1.2
# BPH
# OA with chronic back pain
# sacral gluteal erosion; h/o MRSA cellulitis
# laminectomy L5-S1,
# anterior cervical discectomy with fusion C3 through 4 and C5
through 6, compression laminectomy C3 through 7, arthroscopy of
the knee, toe abscess x2.
Social History:
lives in [**Location **] with wife
Family History:
non-contributory
Physical Exam:
T BP 120/66 HR 81 (sinus) RR 14, 98%
Gen: Intubated, sedated, morbidly obese. Opens eyes to command
CV: RRR no m/r/g; decreased heart sounds
Pulm: clear anteriorly
Abd: obese, s/nd/nt + BS, PEG in place (non-functional
Ext: B chronic venous changes, trace edema B
Pertinent Results:
EP study showed scar and many foci were ablated with some
success, but residual foci.
.
cardiac cath had LAD stenosis and bare metal stent was placed.
Brief Hospital Course:
A/P 58 yo with PMH significant for morbid obesity, atrial
fibrillation, tonsillar CA s/p chemo/XRT, found down with
ventricular fibrillation with several episodes of recurrent VT
s/p VT ablation.
.
# Cardiac
1. Rhythm: Pt with VF and recurrent monomorphic VT (RBBB
superior morphology). Changed to an altered morphology and some
polymorphic variation s/p 1x ablation. EP study on [**1-14**]- Several
different morphologies of VT were noted, generally not
well-tolerated hemodynamically which limited the ability to map
the arrhythmia. A substrate based ablation was performed which
modified but did not completely eliminate the VT.
Post-ablation, the pt was treated with metoprolol, amiodarone,
and mexilitine. Post-ablation, the pt continued to have
occasional episodes of VT including poorly tolerated spells.
Many of these were associated with increased catecholamine
states such as reducing the amount of sedatives he was receiving
but they did not well respond to increased beta blockade.
BEcause of the concern re: ischemia contributing to the episodes
of arrhythmia, the pt underwent cardiac catheterization (see
below). Following stent placement, there was a marked reduction
in the amount of arrhythmia the pt was having. On [**2156-1-30**] the
pt suffered a Vtach arrest/PEA. Agressive resuscitative
measures were performed but the pt had persistent and recurrent
arrhythmia that was not hemodynamically tolerated and did not
respond to repeated attempts at defibrillation. ECG during
brief sinus rhythm during code did not demonstrate ST elevation
or any evidence of acute stent thrombosis. Code was called
after 30 minutes. Pronounced dead.
.
2. CAD: Reduced EF, and findings at EP study consistent with CAD
(regional scar), although cardiac enzymes persistantly negative.
Medically treated with ASA, BB, plavix, statin, ACEI. Had cath
and bare metal stent to prox LAD which markedly reduced the
amount of arrhythmia he was having.
.
3. Pump: LVEF now 30% with 1-2+MR and mild PAH. Treated with
furosemide for diuresis.
.
# Altered mental status: likely was ICU/sedation induced
delirium. Head CT without bleed or infarct. Remained confused
but improved by time of death.
.
# Infection: Patient had E. coli UTI which was treated with 7day
ceftriaxone. MRSA PNA being treated with vancomycin treated with
15 days. Treated with ceftaz for moraxilla and pseudomonas PNA.
.
# Diarrhea: Likely secondary to antibiotics. decreased with
immodium. c.diff neg x 4
.
# Respiratory failure: Intubated and extubated during
hospitalization. Monitored for hypoxia (h/o pulmonary edema,
pna, OSA). Thick secretions still ([**1-13**] parotid after surgery);
improved on humidified oxygen. saline nebs. CPAP at night
.
# Diabetes: Treated with SSI and NPH [**Hospital1 **].
.
# Tonsillar Cancer: tonsillar CA s/p 3x cisplatin ([**2155-11-3**],
[**2155-11-24**], [**2155-12-15**]) and XRT (finished [**12-22**]). Had good
prognosis according to Oncologist:Dr. [**Last Name (STitle) 19101**] [**Telephone/Fax (1) 19102**].
.
# Pressure ulcers: 2 small spots on back and under pannus which
do not look infected. Treated with air bed, Zinc, vit c, wound
care.
.
# FEN/GI: Tube feeds.
Medications on Admission:
Procrit on monthly injections
allopurinol 300mg dialy
amiodarone 200 mg daily,
baclofen 20 mg t.i.d.,
Centrum Silver once daily,
Detrol 4 mg once daily,
Flomax 4 mg once daily,
glyburide 5 mg in the morning 3.75 in the evening,
Lasix 40mg tid,
Lipitor 40 mg daily.,
metformin 500 mg b.i.d.
Neurontin 600 mg t.i.d.,
protonix 40mg daily
potassium 30 once daily,
Proscar 40
Toprol-XL 50 once daily,
Wellbutrin SR 150 t.i.d.
Vicodin 500 mg t.i.d.
vit b12
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
V. Tach arrest
Coronary artery disease
Diabetes
OSA
CHF EF of 40%
1st degree AV block
COPD/asthma
CKD
Secondary
GERD/PUD
Stage 4 tonsillar cancer treated with chemo and radiation
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 4271, 4254, 5859, 496, 5990, 4280, 4275, 3572, 412 | [
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train_11035 | completed | 83d44bb2-168d-4e13-a2c3-9d81b12cb457 | Medical Text: Admission Date: [**2118-4-11**] Discharge Date: [**2118-4-12**]
Date of Birth: [**2052-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
pre-syncope
Major Surgical or Invasive Procedure:
EGD x 1
History of Present Illness:
Mr. [**Known firstname 97961**] [**Known lastname **] is a very nice 66 year-old gentleman with
atrial fibrillation on coumadin who comes after a near-syncopal
episode with melena. He was in his prior state of health until 2
months ago when he started feeling fatigued and noticing very
small ammount of blood in his mouth in the mornings that he did
not pay much attention to. He denies any abdominal pain,
epigastric pain, easy bruising or bleeding. Yesterday he states
he did not feel good and that he had 5 loose bowel movements
(not watery) that were normal in color. He woke up in to go to
the bathroom to move his bowels and had [**Last Name (un) 23550**] stools, then on
his way back to the bed he felt dizzy, diaphoretic and fell to
the floor. He did not hit his head or lost consciousness. He dit
not feel confused or exhausted afterwards and there was no aurea
beforehand. He was transfered to the [**Hospital1 18**] for further
evaluation.
.
In the ER his initial VS were Pain 0/10, T 97.2 F, HR 63 BPM, BP
114/64 mmHg, RR 16 X', SpO2 100% on RA. His initial physical
exam he looked normal. His HCT was 24.3 from baseline of 35 on
[**8-22**] according to Atrius Notes and an INR of 2.7. Pt underwent
NG-lavage with brown fluid and after 500cc started to clear to a
pink fluid. However, they started to see [**Last Name (un) 97962**] blood afterwards.
Patient was started on IV pantoprazole gtt, received 4 mg of
zofran for nausea, was T&C and was ordered for 2 RBC Units and 2
units of FFP. He received 3 L of NS. After I discussed with ER
team, they decided to call GI and finally accepted to scope him
tonight in the ICU after elective intubation. Throughout the ER
admission his VS were stable with SBP in 110/70, HR 60 (on
diltiazem) prior to transfer. He has 2 18G for access.
Past Medical History:
* Diabetes Mellitus Type 2
* Hypernteion
* Dyslipidemia - Chol 160 HDL 44 LDL 61, TG 80 [**2-23**]
* Paroxysmal atrial fibrillation on coumadinm rate and
controlled with diltiazem
- S/p Appendectomy in [**2100**]
Social History:
He lives in [**Location 669**] with his wife. Denies any current or past
history of smoking, drinking or illegal substance use. He used
to work in the construction business and may have been exposed
to absestos.
Family History:
Denies history of MI
Physical Exam:
VS:
GENERAL - well-appearing man in NAD, comfortable, appropriate,
jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-18**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
[**2118-4-11**] 12:30AM BLOOD WBC-10.1 RBC-2.89*# Hgb-8.2*# Hct-24.3*#
MCV-84 MCH-28.5 MCHC-33.9 RDW-13.1 Plt Ct-227
[**2118-4-11**] 05:00AM BLOOD WBC-8.8 RBC-2.15*# Hgb-6.4* Hct-18.1*#
MCV-84 MCH-29.6 MCHC-35.3* RDW-12.8 Plt Ct-173
[**2118-4-12**] 05:43AM BLOOD WBC-14.3*# RBC-3.50*# Hgb-10.7*#
Hct-29.6* MCV-85 MCH-30.6 MCHC-36.1* RDW-13.5 Plt Ct-171
[**2118-4-11**] 12:44AM BLOOD PT-27.9* PTT-25.0 INR(PT)-2.7*
[**2118-4-12**] 05:43AM BLOOD PT-19.2* PTT-28.2 INR(PT)-1.8*
[**2118-4-11**] 12:30AM BLOOD Glucose-173* UreaN-54* Creat-1.0 Na-138
K-4.3 Cl-106 HCO3-22 AnGap-14
[**2118-4-12**] 05:43AM BLOOD Glucose-114* UreaN-19 Creat-0.8 Na-139
K-4.0 Cl-109* HCO3-23 AnGap-11
[**2118-4-11**] 12:30AM BLOOD ALT-24 AST-17 LD(LDH)-143 CK(CPK)-135
AlkPhos-44 TotBili-0.1
[**2118-4-11**] 05:00AM BLOOD ALT-23 AST-18 LD(LDH)-112 AlkPhos-35*
TotBili-0.1
[**2118-4-11**] 05:00AM BLOOD Albumin-2.9* Calcium-7.0* Phos-1.8*
Mg-1.6 Iron-54
[**2118-4-11**] 12:30AM BLOOD cTropnT-<0.01
[**2118-4-11**] 05:00AM BLOOD calTIBC-221* VitB12-340 Folate-10.7
Ferritn-27* TRF-170*
[**2118-4-11**] 09:55AM BLOOD freeCa-1.10*
[**2118-4-11**] - EGD report
Impression: Ulcer in the pre-pyloric region Ulcer in the
posterior bulb
The area of the ulcer was swollen raising the possibility of a
mass or cyst pressing on this area. Please obtain CAT scan to
make sure that there is o abnormality, Otherwise normal EGD to
second part of the duodenum
Recommendations: If any questions or you need to schedule an
[**Telephone/Fax (1) 682**] or email at [**University/College 21854**]. Ulcers
unlikely to rebleed give PPI [**Hospital1 **] for one week then daily, then
once daily. Check H. pylori antibody. Can restart coumadin in 72
hours if needed.
Brief Hospital Course:
Mr. [**Known firstname 97961**] [**Known lastname **] is a very nice 66 year-old gentleman with
atrial fibrillation on coumadin who comes after a near-syncopal
episode with melena and active upper GIB.
# Upper GI bleed - Patient on coumadin with INR of 2.7 coming
with melena, hemoptysis, active bleeding on NG-lavage and
pre-syncope with signs of hyperdynamic cardiovascular
hemodynamics, but stable VS. He drop from 35--->24 in hct, for
which he received total of 4 units PRBC, 4 units FFP, and
vitamine K. EGD showed a gastric ulcer (likely source of
bleed). There was extrinsic compression of stomach suggestive
of a mass (?pancreatic). Patient was suggested to follow up
with GI for outpatient workup with CT abdomen.
# Anemia - Pt with normocytic normochromic anemia with normal
RDW, most likely acute bleed.
# Diabetes Mellitus Type 2 - He is controlled with metfromin and
glyburide. He was placed on ISS due to bleed, strict NPO. He
was placed back on home meds at the time of discharge.
# Hypertension - Patient with normal BP, but due to bleeding,
home medications were held.
# Dyslipidemia - Chol 160 HDL 44 LDL 61, TG 80 [**2-23**] recently.
Held simvastatin given strict NPO for possible intubation and
EGD. Lipitor was resumed after patient tolerated PO.
# Paroxysmal atrial fibrillation - on coumadinm rate and
controlled with diltiazem. CHADS2 2.
# FEN - Strict NPO.
# Access - PIV with 18G x2
# PPx -
-DVT ppx with pneumoboots
-Bowel regimen colace/senna
-Pain management with morphine IV
# Code - Full code.
# Dispo - ICU until HCT stable and EGD.
# [**Name (NI) **] - Wife [**Telephone/Fax (1) 97963**].
Medications on Admission:
Diltiazem SR 360 Daily
Glyburide 5 mg PO daily
Metformin 1000 PO BID
Simvastatin 80 mg PO Daily
Coumadin 4 mg as directed
Viagra 50 mg PO PRN sex
Lisinopril 10 mg PO
Discharge Medications:
1. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: start tonight.
Disp:*14 Tablet(s)* Refills:*0*
3. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: Three (3)
Capsule,Degradable Cnt Release PO once a day.
4. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. Viagra 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for sexual intercourse.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI Bleed
Gastric Ulcer
Duodenal Ulcer
P. Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with a bleed from an ulcer in your stomach.
This was made worse by the way that Coumadin thins your blood.
Additionally, you developed a pneumonia. You must follow up with
your PCP and complete the antibiotics as prescribed for your
pneumonia. Do not take coumadin until directed by your PCP.
Because of the shape of your stomach, we strongly reccommend
that you get a CT scan of your abdomen
START - Pantoprazole - an acid reducer for your ulcer.
START - Augmentin - an antibiotic
STOP - Coumadin - restart when instructed by your PCP
Followup Instructions:
APPOINTMENT WITH DR. [**Last Name (STitle) **] - [**Telephone/Fax (1) 80426**] - THURSDAY at 12pm
Please follow up with the gastroenterology team in [**2-16**] months.
You can get an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 86507**].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 2851, 4019, 2724 | [
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train_9250 | completed | 4f3dd627-0f06-467e-a910-5f8a9f970009 | Medical Text: Admission Date: [**2145-3-5**] Discharge Date: [**2145-3-9**]
Date of Birth: [**2075-11-6**] Sex: M
Service: CCU
The patient was a 69-year-old man with history of tobacco
use, hypertension, hypercholesterolemia, diabetes mellitus,
and known coronary artery disease, but no known details, who
was admitted to an outside hospital after a cardiac arrest at
home, status post multiple electrical cardioversion attempts,
started on amiodarone drip, as well as status post
intubation. The patient was transferred to [**Hospital1 18**] for
emergent coronary catheterization, but no intervention was
possible in the coronary catheterization laboratory.
The patient was admitted to the coronary care unit for
further management. The patient's cardiac and pulmonary
status remained stable on multiple medications and on the
ventilator. The patient's sedation was decreased in order to
better assess neurological function. Neurology consult also
followed the patient. After a long discussion with the
family and also with neurology input as well as with the
medical team, the family decided to make the patient comfort
measures only. The patient was, therefore, extubated on
[**2145-3-9**] and passed away on that day.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], [**MD Number(1) 22954**]
Dictated By:[**Last Name (NamePattern1) 4959**]
MEDQUIST36
D: [**2145-7-28**] 14:47:53
T: [**2145-7-29**] 05:46:24
Job#: [**Job Number 34398**]
ICD9 Codes: 4271, 5070, 5990, 5849, 4019 | [
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] | [
"6b907695-7d26-4ebc-843d-9769e96a2f35"
] | [
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] | [
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] | [
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train_9413 | completed | 2a55ecaa-140e-4dcc-81c1-212f6a80fc21 | Medical Text: Admission Date: [**2142-9-4**] Discharge Date:
Date of Birth: [**2090-4-5**] Sex: F
Service: Card/[**Last Name (un) **]
ATTENDING:[**Last Name (STitle) 35289**]
HISTORY: The patient is a 52-year-old female who presented
with shortness of breath on exertion and chest pain over the
last year. The ejection fraction was estimated to be 77%.
Cardiac catheterization showed a moderate aortic stenosis.
The RA is 8, PAP is 13/8, wedge is 7, A-V gradient is 39, M-V
and A-V are normal, via catheterization.
PAST MEDICAL HISTORY: History is significant for aortic
stenosis on echocardiogram. History is significant for
hyperlipidemia and cesarean section in [**2115**].
MEDICATIONS: (Home)
1. Prempro .625/2.5, one tablet p.o. q.d.
2. Atenolol 25 mg p.o.q.d.
3. Fortaz XT, 120 mg p.o.q.d.
4. Aspirin 325 mg p.o.q.d.
The patient was taken by Dr. [**Last Name (STitle) **] to the OP. The
patient underwent Bentall procedure on [**2142-9-4**].
Postoperatively, the patient did well. She was subsequently
extubated and weaned off drips. She was discontinued chest
tube and transferred to the floor. Postoperatively, on the
floor, the patient did well. The patient was ambulated at
level 5. She was able to climb stairs before discharge to
home.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o.b.i.d.
2. Lasix 20 mg p.o.b.i.d. times five days.
3. [**Doctor First Name 233**]-Ciel 20 mEq p.o.b.i.d.
4. Aspirin 81 mg p.o.q.d.
5. Prempro .625/2.5, one tablet p.o.q.d.
FOLLOW-UP CARE: The patient was told to followup with
Dr. [**Last Name (STitle) **] in three to four weeks. The patient requested
not to have home nursing care.
Upon discharge, the patient's vitals were stable. Her blood
pressure was running at 122/80, heart rate was about 79 to
80. She was saturating at 95% on room air.
PHYSICAL EXAMINATION: Examination included the heart rate
with regular rate and rhythm, normal sinus. The incision was
clean, dry, and intact, no drainage, no pus, and sternum
stable. The patient was afebrile on discharge.
[**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2142-9-7**] 09:46
T: [**2142-9-7**] 09:49
JOB#: [**Job Number 35290**]
ICD9 Codes: 4241, 2724, 3051 | [
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] | [
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] | [
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train_11379 | completed | 5b4a1f90-ff08-497d-8df5-afe0461a0490 | Medical Text: Admission Date: [**2132-7-21**] Discharge Date: [**2132-7-23**]
Date of Birth: [**2071-8-26**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female who was watching television with her husband on [**7-21**] when she then fell to the floor and was unresponsive.
Her husband then performed CPR and called paramedics. The
paramedics then arrived, placed external defibrillator on the
patient. The patient was shocked three times. The patient
then regained normal sinus rhythm and was sent to [**Hospital6 3426**]. At [**Hospital6 33**] the patient was intubated
and transferred to [**Hospital1 69**]. The
patient has no previous medical problems. Upon admission,
the patient was intubated.
PHYSICAL EXAMINATION: Physical examination was significant
for an obese, somewhat agitated and combative patient. On
physical examination, her head and neck examination revealed
pupils were equally round and reactive. Her extraocular
movements were intact. She was anicteric. Her neck was not
evident for jugular venous distention. Her lung examination
was clear to auscultation anteriorly and laterally. Her
cardiac examination revealed a regular rate and rhythm, S1,
S2. No murmurs, rubs or gallops. On abdominal examination,
she was obese. Her abdomen was non-distended, non-tender and
she had normoactive bowel sounds. Extremity examination
showed intact pulses bilaterally, no clubbing, cyanosis or
edema but did show a left ganglionic cyst. Her neuro
examination was nonfocal. She moved all four limbs equally.
RADIOLOGY: Patient had a head CT which was negative. She
had a chest x-ray which was negative except for a small
calcification which may be significant for a tooth.
LABORATORY: Patient's Chem-7: Sodium 141, potassium 4.1,
chloride 103, bicarb 29, BUN 20, creatinine 1.3, glucose 163.
Patient's initial CBC: White count 13.8, hemoglobin 13.3,
hematocrit 38.4, platelets 270. Her PT 13.0, PTT 23, 8, INR
1.1. Patient's d-dimer less than 500. Urinalysis was
negative. Troponin of 0.1, CK MB 13, MB index of 1.8%
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Last Name (NamePattern1) 6289**]
MEDQUIST36
D: [**2132-7-23**] 15:35
T: [**2132-7-23**] 17:56
JOB#: [**Job Number 51282**]
ICD9 Codes: 4019 | [
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train_10065 | completed | 748a208a-1172-4a22-a005-c2f3f44978eb | Medical Text: Admission Date: [**2185-1-3**] Discharge Date: [**2185-1-9**]
Date of Birth: Sex: F
Service: Medicine
CHIEF COMPLAINT: Chronic renal failure and metabolic
acidosis.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
female with a history of chronic renal insufficiency (with a
baseline creatinine of 2.1 to 3), type 2 diabetes, bilateral
staghorn calculi, and presumed diastolic dysfunction,
peripheral vascular disease, and atrial fibrillation now
being transferred from Medical Intensive Care Unit to the
Medicine Service following treatment for acute-on-chronic
renal failure with anion gap metabolic acidosis.
Per report, the patient was evaluated by primary care
physician on [**1-3**] for markedly decreased urine output
and increased lower extremity edema and swelling times
several days. No chest pain. No shortness of breath.
Decreased oral intake. Of note, the patient was in the midst
of completing a 14-day course of ciprofloxacin starting on
[**12-17**] for Klebsiella cellulitis.
On Emergency Department evaluation on [**1-3**], the
patient was found with a blood urea nitrogen and creatinine
of 156 and 5.1 and had a fractional excretion of sodium that
looked to be prerenal in etiology. The patient received
Levaquin, Lasix, and normal saline in the Emergency Room and
had a bicarbonate which was decreased from 16 to 6 with a pH
on arterial blood gas of 7.16.
The patient was subsequently transferred to the Medical
Intensive Care Unit with a Renal consultation and was started
on aggressive fluids and bicarbonate drip. In the Medical
Intensive Care Unit, a renal ultrasound was without
significant hydronephrosis. She continued to receive
aggressive hydration, and her creatinine improved to 4.6,
while a repeat arterial blood gas showed a pH of 7.28, and
her chemistries showed a bicarbonate which had increased to
20. She continued to be followed by Renal and was
recommended to be transferred to the floor with continued
gentle intravenous fluids with continued bicarbonate
repletion.
PAST MEDICAL HISTORY:
1. Chronic renal insufficiency (with a baseline creatinine
of 2.1 to 3).
2. Bradycardia; status post pacemaker.
3. Type 2 diabetes.
4. Congestive heart failure; presumed diastolic (with an
ejection fraction of 55% to 60% in [**2184-3-20**]).
5. Bilateral staghorn calculi.
6. Paroxysmal atrial fibrillation.
7. Hypertension.
8. Hyperlipidemia.
9. Status post right upper extremity deep venous thrombosis
presumed secondary to central line.
10. Iron deficiency anemia.
11. Peptic ulcer disease.
12. Peripheral vascular disease; status post left popliteal
posterior tibial bypass via saphenous vein graft.
13. Status post left fifth toe amputation and left
transmetatarsal amputation.
14. Klebsiella bacteremia in [**2184-1-21**].
15. Recent Klebsiella cellulitis.
ALLERGIES: Allergies include SULFA (to which she gets
hives).
MEDICATIONS ON ADMISSION: (Her medications at home included)
1. Ciprofloxacin 500 mg by mouth once per day.
2. Hydralazine 250 mg by mouth four times per day.
3. Lopressor 100 mg by mouth twice per day.
4. Hydrochlorothiazide 25 mg by mouth once per day.
5. Zoloft 50 mg by mouth once per day.
6. Colace.
7. Tylenol.
8. Lipitor.
9. Heparin subcutaneously.
10. Isosorbide dinitrate 20 mg by mouth twice per day.
11. Aspirin 81 mg by mouth once per day.
12. Glipizide 5 mg by mouth once per day.
13. Ambien.
14. Multivitamin.
MEDICATIONS ON TRANSFER: (In the hospital, her medications
at the time of transfer included)
1. Epogen 5000 units every Tuesday and [**Year (4 digits) 2974**].
2. Hydralazine 10 mg q.6h.
3. Amphojel 30 mg q.8h.
4. Coumadin 5 mg by mouth at hour of sleep.
5. Zantac 150 mg by mouth once per day.
6. Glipizide 5 mg by mouth once per day.
7. Senokot.
8. Aspirin.
9. Isosorbide dinitrate 20 mg by mouth twice per day.
10. Lipitor 10 mg by mouth at hour of sleep.
11. Colace.
12. Zoloft.
13. Metoprolol 100 mg by mouth twice per day.
14. Insulin sliding-scale.
SOCIAL HISTORY: The patient is a Russian-speaking female. A
former computer technician who lives alone in [**Location (un) 745**] and
claims to be highly independent.
PHYSICAL EXAMINATION ON PRESENTATION: At the time of
admission her vital signs revealed a temperature of 98.4
degrees Fahrenheit, her blood pressure was 132/80, her heart
rate was 60, her respiratory rate was 20, and her oxygen
saturation was 96% on room air. In general, she was an
obese, elderly, Russian-speaking female sitting comfortably
in bed. Head, eyes, ears, nose, and throat examination
significant for upper palate with dentures. Difficult to
assess jugular venous distention secondary to a large body
habitus. Cardiovascular examination revealed first heart
sound and second heart sound with a 2/6 systolic ejection
murmur at the left sternal border. Pulmonary examination
revealed bibasilar crackles (right greater than left) about
one quarter to two thirds of the way from base. Abdominal
examination revealed positive bowel sounds. Ecchymosis in
the right lower quadrant. The abdomen was soft, nontender,
and nondistended. Extremities showed bilateral upper
extremity edema. Left lower extremity with a bandage.
PERTINENT LABORATORY VALUES ON PRESENTATION: Her white blood
cell count was 8.2, her hematocrit was 28.7 (down from 32.5),
and her platelets were 221. Chemistries revealed her sodium
was 139, potassium was 3.5, chloride was 103, bicarbonate was
20, blood urea nitrogen was 149, and her creatinine was 4.6
(down from 4.8 and 5.1). Her calcium was 6.3, magnesium was
2.7, and her phosphate was 12.2 (down from 13.8). Her INR
was 2.6. Her albumin was 3.1, aspartate aminotransferase was
23, alanine-aminotransferase was 44, her lactate
dehydrogenase was 167, her alkaline phosphatase was 213, and
her total bilirubin was 0.2. Most recent arterial blood gas
was 7.28/41/87. She had a lactate of 0.8. Her
thyroid-stimulating hormone was 1.6.
PERTINENT RADIOLOGY/IMAGING: Her renal ultrasound (as
mentioned above) showed minimal left-sided hydronephrosis at
3.4 cm X 3.6 cm X 1.5 cm cyst within the upper pole of the
right kidney.
She had an echocardiogram on [**1-5**] which showed an
ejection fraction of 60%, tricuspid gradient of 42 to 47,
with moderate pulmonary hypertension, dilated left and right
atrium, mid symmetric left ventricular hypertrophy, normal
left ventricular cavity size, mildly dilated aortic root, 1+
to 2+ mitral regurgitation, and moderate 2+ tricuspid
regurgitation.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RENAL ISSUES: The patient was admitted with acute renal
insufficiency and metabolic acidosis. Given the degree of
her acidemia with a pH of 7.16, she was initially transferred
to the Medical Intensive Care Unit where she received
aggressive hydration with bicarbonate supplementation. By
the time of her transfer to the Medicine Service, her
creatinine had shown slow signs of improvement and her
acidosis seemed to be much improved from admission, as her
bicarbonate had increased from 6 to 20.
The exact etiology of her renal insufficiency remained
unclear. [**Name2 (NI) 227**] her recent use of antibiotics and several
eosinophils in the urine, there was concern for an acute
interstitial nephritis. It was also felt that possibly the
patient could have been severely prerenal with a recent
decrease in her oral intake and being on a diuretic. There
was also concern that the patient may have a degree of renal
artery stenosis. Finally, there was concern given her
history of calculi that the patient may have some type of
postobstructive renal insufficiency.
Further review of her initial renal ultrasound, however, did
not indicate significant left-sided hydronephrosis. Given
that the patient was ineligible for magnetic resonance
imaging given a pacemaker, it was decided that she may
qualify for a follow-up ultrasound as an outpatient for
further evaluation of possible renal artery stenosis and
re-evaluation of hydronephrosis.
While on the floor, the patient was given gentle intravenous
fluids with bicarbonate. Her urine output increased
markedly, and she was given fluids to help keep up with her
losses. Her creatinine also showed marked improvement,
decreasing to 2.9 by the day of discharge. Meanwhile, the
patient was continued on phosphate binders for her elevated
phosphorous; she had received calcium carbonate and aluminum
hydroxide. She was instructed to continue on calcium
carbonate 1000 mg three times per day as an outpatient.
The true etiology of the patient's renal insufficiency
remained unclear. [**Name2 (NI) 227**] the fact that her response to
intravenous fluids, though, it was thought that the patient
had a significant prerenal dysfunction. For this reason, her
hydrochlorothiazide was held throughout her hospital course,
and her blood pressure was controlled with beta blockers,
nitrates, and hydralazine. She was due for a laboratory
check status post discharge to assess whether or not she
should resume her hydrochlorothiazide.
2. CARDIOVASCULAR ISSUES: (a) Pump function: The patient
was found to have a normal ejection fraction on an
echocardiogram during this admission. She was presumed to
have diastolic dysfunction as the cause of her congestive
heart failure. The patient did have rales in her lungs
throughout her hospital course but remained compensated
during her hospitalization, saturating well off oxygen.
(b) Hemodynamics: From a hemodynamic standpoint, was found
to have elevated blood pressures during her hospital course.
Her hydrochlorothiazide was discontinued secondary to
concerns about her renal insufficiency. Meanwhile, her beta
blocker was increased from 100 mg twice per day to 100 mg
three times per day. Her hydralazine was titrated from 10 mg
to 50 mg by mouth q.6h., and her isosorbide dinitrate was
increased from 20 mg twice per day to 20 mg three times per
day.
She was scheduled to be evaluated as an outpatient one to two
days status post discharge for additional blood pressure
measurements and electrolyte checks to determine whether it
would be safe to resume her hydrochlorothiazide at this
point.
(c) Rhythm: From a rhythm standpoint, the patient has a
history of atrial fibrillation. She was paced during her
hospital course. She was continued on Coumadin once her INR
was verified. She was to continue at 5 mg by mouth at hour
of sleep. She was also continued on aspirin and Lipitor.
3. PULMONARY ISSUES: Although the patient had rales on
pulmonary examination, the patient continued to saturate well
off nasal cannula oxygen during her hospitalization.
4. HEMATOLOGIC ISSUES: The patient was anemic during her
hospitalization on the floor. She did not require a
transfusion; however, she was continued on Epogen 5000 units
every Tuesday and [**Name2 (NI) 2974**]. She was continued on Coumadin for
a history of atrial fibrillation. She was to go home on 5 mg
by mouth at hour of sleep of Coumadin. The patient had
difficult vascular access. Given concerns about an elevated
INR on Coumadin, the patient had a right-sided peripherally
inserted central catheter line placed on [**1-7**] that was
subsequently discontinued at the time of her discharge.
5. INFECTIOUS DISEASE ISSUES: The patient was completing a
14-day course of ciprofloxacin for Klebsiella cellulitis. She
remained afebrile during her hospital course.
Meanwhile, she was evaluated by both Vascular Surgery and
Podiatry for a wound at the site of her left transmetatarsal
amputation. It was recommended that the patient continue on
wet-to-dry Regranex dressings twice per day. Per Podiatry,
she also had her right toenails debrided.
6. ENDOCRINOLOGY ISSUES: The patient maintained excellent
blood sugar control on her glipizide and insulin
sliding-scale.
DISCHARGE DIAGNOSES:
1. Acute-on-chronic renal failure of unclear etiology;
resolved.
2. Metabolic acidosis; resolved.
3. Hypertension.
4. Type 2 diabetes.
5. Status post left-sided transmetatarsal amputation; wound
site stable.
6. Status post debridement of right toenails.
CONDITION AT DISCHARGE: Her Condition on discharge was fair.
MEDICATIONS ON DISCHARGE: (Her discharge medications
included)
1. Zoloft 50 mg by mouth once per day.
2. Colace 100 mg by mouth twice per day.
3. Lipitor 10 mg by mouth once per day.
4. Glipizide 5 mg by mouth once per day.
5. Hydralazine 50 mg by mouth q.6h.
6. Coumadin 5 mg by mouth at hour of sleep.
7. Metoprolol 100 mg by mouth three times per day.
8. Isosorbide dinitrate 20 mg by mouth three times per day.
9. Zantac 150 mg by mouth once per day.
10. Aspirin 81 mg by mouth once per day.
11. Regranex 0.01% gel applied topically once per day.
12. Calcium carbonate 1000 mg by mouth three times per day
(with meals).
13. Insulin sliding-scale.
14. Ambien by mouth at hour of sleep.
15. Epogen 5000 units every Tuesday and [**Month (only) 2974**].
16. Senokot by mouth twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with her primary
care physician (Dr. [**Last Name (STitle) **] in one to two days for a blood
pressure check and check of her INR and electrolytes to
determine whether it was okay for her to resume diuretic.
2. The patient was also to go home with [**Hospital6 1587**] services for her wound care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D.
Dictated By:[**Last Name (NamePattern1) 5539**]
MEDQUIST36
D: [**2185-3-20**] 14:25
T: [**2185-3-22**] 07:47
JOB#: [**Job Number 105319**]
ICD9 Codes: 5849, 4280, 2762, 2765, 2767, 2859 | [
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train_10109 | completed | 58ec31cb-5d2e-4a08-afb1-78e592a2a7fc | Medical Text: Admission Date: [**2149-12-26**] Discharge Date: [**2150-1-1**]
Date of Birth: [**2069-8-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Tape
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
transferred from outside hospital for evaluation of possible
aortic dissection
Major Surgical or Invasive Procedure:
R subclavian venous catheter placement complicated by apical
pneumothorax
R chest tube placement
L femoral hemodialysis catheter placement
continuous [**Last Name (un) **]-venous hemodialysis
History of Present Illness:
Mr. [**Known lastname 70876**] is an 80 yo male with h/o DM type II, CRI, Aortic
stenosis (valve area 0.75 cm2), carotid stenosis and h/o CVA who
was transferred from OSH [**2149-12-26**] for evaluation of back and arm
pain concerning for possible aortic dissection.
.
Per pt's daughter the pt started complaining of backpain and had
elevated blood pressures three nights ago. The next morning he
had severe left arm pain, which radiated around to the right
side. He took some advil and was taken to [**Hospital3 **] on
[**12-25**]. Daughter notes there he had transient right arm and leg
weakness. Per OSH notes he was c/o an upper abdominal tearing or
pulling sensation. In the ER BP was 208/58 and he was treated
with labtetolol and nitroprusside. He had a non-contrast CT of
the chest which showed heterogenous attenuation of the
descending aorta and it was difficult to exclude dissection.
Head CT was negative for acute event. There was also some
concern that the patient had weakness in his arms and legs and
that potentially there was a spinal cord infarction from a
dissection at the T8 level. He was sent to [**Hospital1 **] for further
evaluation of dissection.
.
Pt arrived to [**Hospital1 **] and was responsive upon arrival. He was started
on a labetolol gtt. Overnight UOP decreased and he received 2
units of PRBC for hct of 26.2 (down from 33). He was started on
levophed, but in the AM noted to be less responsive. The
vascular surgery team asked for MICU evaluation.
.
Upon MICU evaluation the patient was not responding to questions
and was requiring increasing doses of levophed. His O2 sats
started dropping to the low 90s on nasal cannula O2 and he was
placed on a NRB. He became acutely bradycardic to the 30s and
hypotensive to systolics in the 60s. He was given one amp of
atropine and his HR and blood pressure improved. He was also
given 0.4 mg of naloxone. His breathing appeared slow and
labored so he was intubated at that time.
Past Medical History:
Aortic Stenosis (valve area 0.75 cm2 in [**2146**])
Type 2 Diabetes
Right carotid stenosis
CRI
CVA
hypothyroidism
h/o TB
Laryngeal cancer s/p chemo in [**2133**]
Social History:
Lives alone
Quit drinking and smoking in the early 90s
No drugs
Family History:
Significant for diabetes
Physical Exam:
On arrival to MICU:
VS: T 95.1 BP 102/31 HR 52
AC: 600 x15 FiO2 40% PEEP 5
Gen: elderly gentleman, eyes opening, not responding to voice,
rhythmically moving tongue
HEENT: Pinpoint pupils, minimally reactive to light, dry MM
intubated
Neck: supple
Pulm: rhonchi and wheezes bilaterally
Cardio: RRR, 3/6 systolic murmur loudest LLSB
Abd: soft, NT, ND, hypoactive BS
Ext: no peripheral edema, palpable pulses
Neuro: Pt's eyes open, looks around room, does not respond to
voice or commands
Upper extremities flacid
Moving toes in left foot
Upgoing Babinski's bilaterally
Pertinent Results:
[**2149-12-26**] 04:04PM WBC-12.0* RBC-5.35 HGB-10.7* HCT-33.0*
MCV-62* MCH-20.0* MCHC-32.4 RDW-17.5*
[**2149-12-26**] 04:04PM PLT COUNT-264
[**2149-12-26**] 04:04PM PT-12.5 PTT-36.0* INR(PT)-1.1
[**2149-12-26**] 04:04PM TSH-1.4
[**2149-12-26**] 04:04PM ALBUMIN-3.9 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-2.2
[**2149-12-26**] 04:04PM CK-MB-6 cTropnT-0.03*
[**2149-12-26**] 04:04PM LIPASE-41
[**2149-12-26**] 04:04PM ALT(SGPT)-10 AST(SGOT)-13 LD(LDH)-159
CK(CPK)-225* ALK PHOS-89 AMYLASE-62 TOT BILI-0.4
[**2149-12-26**] 04:04PM GLUCOSE-330* UREA N-53* CREAT-3.7* SODIUM-137
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2149-12-26**] 06:01PM URINE WBCCLUMP-MANY
[**2149-12-26**] 06:01PM URINE RBC-686* WBC-929* BACTERIA-NONE
YEAST-NONE EPI-0
[**2149-12-26**] 06:01PM URINE BLOOD-LGE NITRITE-POS PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2149-12-26**] 06:01PM URINE COLOR-[**Location (un) **] APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2149-12-26**] 11:49PM CK-MB-5 cTropnT-0.03*
[**2149-12-26**] 11:49PM CK(CPK)-181*
[**2149-12-26**] 11:49PM GLUCOSE-230* UREA N-59* CREAT-4.5* SODIUM-139
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-16* ANION GAP-19
[**2149-12-26**] 11:59PM freeCa-1.27
[**2149-12-26**] 11:59PM GLUCOSE-215* LACTATE-2.9* K+-4.8
[**2149-12-26**] 11:59PM TYPE-ART PO2-91 PCO2-37 PH-7.31* TOTAL
CO2-20* BASE XS--6
.
Diagnostics:
OSH:
Cartotid duplex
right carotid: 90% stenosis of proximal common carotid, internal
carotid artery 75% stenosis
left carotid: 60-69% stenosis in the internal carotid artery
.
ECHO [**12-25**]: EF 50%, moderate LVH, severec calcification of aortic
valve with mean gradient 35 mm hg
mitral annular calcification, MR, TR
.
CT head: large chronic cystic lesions in posterior fossa,
bifrontal atrophy, multiple lacunar infarcts with apparent
lesions in the external capsule bilaterally as well as the right
internal capsule
.
[**Hospital1 **] diagnostics:
CXR [**12-27**]: Right subclavian vascular catheter terminates in the
lower superior vena cava. Cardiac silhouette is upper limits of
normal in size. The aorta is tortuous and calcified. Patchy
right basilar atelectasis is present, and there is a
questionable small right pleural effusion.
.
MRI/MRA of chest and abdomen: no aortic dissection, intramural
thrombus, or penetrating ulcer. Large atherosclerotic plaque in
the descending aorta with associated intraluminal thrombus.
.
MRI/MRA Head, Neck C-Spine:
-multiple areas in cerebellar hemispheres, cortex, basal
ganglia, brainstem, C-spine concerning for embolic infarcts
-abnl vertebral signal bilaterally concerning for occlusion vs
dissection
-Diffusely abnormal T2 hyperintense signal involving the
medulla, cervical medullary junction and almost entire aspect of
the cervical cord, involving the lateral and posterior columns,
most likely consistent with a cord edema and possible cord
infarction.
Brief Hospital Course:
A/P: 80 yo male with h/o DM type II, CRI, Aortic stenosis (valve
area 0.75 cm2), carotid stenosis and h/o CVA who was transferred
yesterday for possible aortic dissection now with decreased
responsiveness, oliguria, hypotension and likely sepsis.
.
*Shock: Patient with hypothermia, hypotension, oliguria and
known source of infection in the urine, so likely had urosepsis.
Other sources for sepsis could be line infection, PNA or
endocarditis. Hypotension most likely [**1-23**] to sepsis but could
represent cardiogenic shock possible [**1-23**] to AMI. AS likely
further contributing to patient's inability to maintain
appropriate cardiac output. He was initially maintained on
Levophed, now off since 0200 on [**12-29**]. A cosyntropin stim test
showed minimal response, 30.5-> 29.7-> 32.9, so hydrocortisone
50 mg q6 started [**2149-12-28**]. Urine with CNS > 100,000 colonies of
SA, sensitive to oxacillin, but continuing Vanc/Zosyn until
other cultures have incubated at least 72 hrs before narrowing
coverage. Echo done to rule out dissection shows no evidence of
aortic valve vegetation; would consider TEE if bacteremic given
severe AS. Required volume and intermittent norepinephrine to
maintain MAP >65.
.
*Mental Status changes/weakness: Patient's MS appears to have
acutely declined overnight after hospital admission. Patient was
conversing with family members day of admissioon and was no
longer responding to voice on MICU transfer. Also had bilateral
upper and lower extremity weakness. There was some concern for
spinal artery infarction at the OSH. MS changes could be [**1-23**] to
encephalopathy from sepsis, renal failure. Could also be [**1-23**] to
acute stroke, cord infarct, or cord compression. No evidence of
seizure activity. Neuro was consulted and MRI/MRA head, Cspine,
Tspine showed stroke, likely embolic, in cerebellum, cortex,
brainstem, Cspine, Tspine.
.
*Hypoxia: Patient's O2 sats had been stable on NC O2. This AM
sats dropped to the low 90s on 6L NC and patient was initially
transitioned to NRB. Lungs sounded rhonchorous bilaterally and
it was thought this was [**1-23**] to volume overload or infectious
process. Patient then became bradycardic and respirations
appeared labored, so he was intubated. Source likely pulmonary
edema in the setting of renal failure and AS. Right-side
pneumothorax detected on CXR; thoracic surgery placed chest tube
to suction. CXR with small R PTX, likely aspiration infiltrate
in LLL. Although he woke up enough to open eyes and move his
tongue, he did not breath over the vent when sedation was
lightened.
.
*Renal Failure: Patient's UOP dropped acutely following
presentation in the setting of hypotension. Pt has chronic renal
insufficiency, but urine lytes c/w pre-renal etiology of ARF. Cr
elevated to 5 and UOP continued to be low. CVVH dialysis
catheter placed in right femoral vein by Transplant Surgery and
CVVHD initiated on [**6-27**]. Renally dose meds. Started aluminum
hydroxide 30 ml TID for hyerphosphatemia. Received CVVH x24 hrs;
after discontinuing, his creatinine immediately trended up; in
the abscence of emergent indication for hemodialysis, repeat
hemodialysis was postponed until a family meeting.
.
*Bradycardia: Patient became acutely bradycardic to the 30's
following transfer and had worsening hypotension. Bradycardia
resolved with atropine. Etiology unclear. Electrolytes were
stable at the time. Could be [**1-23**] to CNS dysfunction, AMI or
medications, as pt had recently been on labetalol gtt.
.
*? aortic Dissection: patient was transferred here for possible
aortic dissection. Per report, the MRI/MRA of the abd was
reviewed by both cardiac surgery and vascular and it appears
there is no dissection, and possibly an old intramural thrombus.
A decision was made not to pursue surgery.
.
*Aortic stenosis: Patient has known critical aortic stenosis.
-hold ACEI in setting of hypotension and renal dysfunction
-High suspicion for endocarditis if bacteremic; would consider
TEE of positive blood cultures
.
* Anemia: Patient has known microcytosis at baseline. Hct at OSH
was 37 and 33 upon arrival here. Hct dropped to 26 yesterday,
without a clear etiology. Bumped to 31 s/p 2 units PRBCs. NOw
33.1.
.
*DM: Maintained on insulin gtt.
.
*Hypothyroidism: cont levothyroxine; adjusted dose for IV
administration.
.
*PPX: heparin, bowel regimen, ppi
.
*FEN: NPO [**1-23**] to aspiration. OG tube placed for TF per nutrition
recs.
.
*Access: R subclavian, right femoral dialysis catheter
.
*Communcation: Daughter, grandson. Family meeting scheduled for
[**12-31**].
Medications on Admission:
Medications at home:
Lisinopril 5 mg qd
Toprol XL 50 mg qd
Tramadol 50 mg po QID
Aggrenox [**Hospital1 **]
Levothyroxine 50 mcg qd
ASA 81 mg qd
Lipitor 40 mg qd
Humalog 2 untis prn
lantus 24 units q AM
colace 200 mg qd
Lasix 20 mg qd
calcitriol 0.25 mcg qd
phoslo 667 [**Hospital1 **]
.
Medications on Transfer:
Morphine prn
ASA 325 mg qd
Calcitriol 0.25 mg qd
Atorvastatin 40 mg qd
Calcium acetate 667 mg PO BID
Insulin gtt
Levophed gtt
Protonix 40 mg IV qd
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
1. multiple cerebrovascular accidents involving the upper
cervical cord, the brainstem, both cerebellar hemispheres, left
frontal
subcortical white matter and basal ganglia including the
cerebral
periventricular white matter
2. Septic shock secondary to urinary tract infection
3. Acute renal failure
Discharge Condition:
Deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
ICD9 Codes: 0389, 5849, 4241, 5990, 5859, 2767, 2859, 2449 | [
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train_9979 | completed | 37896934-0ad6-4f6b-94c3-1f84c02a2235 | Medical Text: Admission Date: [**2169-8-13**] Discharge Date: [**2169-8-24**]
Date of Birth: [**2118-5-5**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Erythromycin Base / Lipitor / Zocor
/ Reglan
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Hemodialysis line placement
Exploratory laparotomy [**2169-8-18**]
Removal of peritoneal dialysis catheter [**2169-8-18**]
History of Present Illness:
51yo M with h/o DM1 on insulin pump, ESRD s/p failed renal
transplant now on PD presented to the ED with 2 days of
abdominal "aches" and 1 day of cloudy peritoneal fluid. Patient
has had previous episodes of peritonitis and had similar
abdominal pain with those episodes. In addition he has had 10X
water stools daily for 2 days, mucousy but not bloody. The
patient does make urine but has not had dysuria. He denies
rhinorrhea, cough, SOB, chest pain, and palpitations. He has had
poor PO intake over the last 2 days but no nausea or vomiting.
.
In the ED, initial vs were T:97.2 HR:79 BP:122/65 RR:14
O2sat:100% on room air. Patient was given CTX and vancomycin for
leukocytosis to 17 and peritoneal fluid and stool cultures were
sent. He complained of abdominal pain that radiated to the left
arm so an EKG was done that showed tachycardia (sinus) with
lateral ST depressions. Cardiac enzymes revealed a troponin of
0.72 (baseline 0.5). Cardiology was called and felt this was
rate-related demand and not acute coronary syndrome. The patient
refused aspirin but because of some hypertension on the floor
did receive and extra 12.5mg of metoprolol.
.
Despite the poor PO intake the patient had been having high
sugars at home. He was on his insulin pump at 0.9 units of
novolog and had also given himself 9 units extra of novolog at
home for FSBS in the 400s. Repeat FSBS on the floor were
persistently in the 400s. The team called [**Last Name (un) 387**] who follows him
as an outpatient. They recommended insulin gtt given that the
patient's initial chem 7 had a FSBS of close to 500 and a new
anion gap (17 with bicarb 19 from baseline 28). For this reason
he is transferred to the ICU.
.
Prior to transfer to the ICU the team spoke with the renal staff
who felt that the patient should receive CTZ rather than CTX for
the peritonitis and thought he could receive around 500mL of
fluids overnight but were hesitant to allow him to get more
because of his dependence on PD and the fact that he would not
be getting PD overnight given the infection.
.
On arrival to the ICU, patient was sleepy, having just received
morphine. He denied pain. Denied recent chest
pain/pressure/dyspnea. No recent headaches, no f/c. Endorsed
above history.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, constipation. Denies dysuria, frequency, or urgency.
.
Past Medical History:
CAD s/p CABGx3 on [**2167-4-14**] (LIMA -> LAD, Vein graft -> [**Female First Name (un) **], Vein
graft -> RCA)
- Type 1 DM c/b retinopathy, neuropathy, nephropathy, and
gastroparesis
- HbA1c in [**6-1**] was 8.5%, on insulin pump
- ESRD [**1-24**] DM: s/p renal transplant [**2148**], recently deteriorating
renal function from chronic allograft nephropathy, started
peritoneal dialysis on [**2167-1-14**], being evaluated for
repeat renal transplant
- Osteomyelitis s/p right 5th digit amputation and abx
- Admission in [**7-/2169**] for gait disturbance [**1-24**] neuropathy and
visual disturbances
- Hypertension
- Hyperlipidemia
- R retinal occlusion w/loss of peripheral vision
- Ulcer on his right hallux (big toe), s/p treatment with Keflex
- Orthostasis
- Depression, sees outpatient psychologist
- GERD
- IBS
Social History:
Lives in [**Hospital1 **] with sister and nephew and dog. No current
tobacco use, but quit >10 yrs ago. No alcohol or drug use.
Family History:
Father died of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 101.7 BP: 156/71 P: 89 R: 18 O2: 95% RA
General: Alert, oriented, no acute distress, somnolent, easily
arousable
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, III/VI mid peaking
systolic murmur at LUSB, no radiation; no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; PD catheter
in place, no erythema near site
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2169-8-13**] 04:55PM PT-12.6 PTT-21.8* INR(PT)-1.1
[**2169-8-13**] 04:55PM PLT COUNT-371
[**2169-8-13**] 04:55PM NEUTS-88.8* LYMPHS-6.6* MONOS-3.3 EOS-1.0
BASOS-0.3
[**2169-8-13**] 04:55PM WBC-17.4*# RBC-3.59* HGB-10.6* HCT-32.8*
MCV-92 MCH-29.4 MCHC-32.2 RDW-18.1*
[**2169-8-13**] 04:55PM LACTATE-1.3 K+-4.4
[**2169-8-13**] 04:55PM COMMENTS-GREEN TOP
[**2169-8-13**] 04:55PM CK-MB-16* MB INDX-5.3
[**2169-8-13**] 04:55PM cTropnT-0.72*
[**2169-8-13**] 04:55PM LIPASE-60
[**2169-8-13**] 04:55PM ALT(SGPT)-43* AST(SGOT)-50* CK(CPK)-302 ALK
PHOS-197* TOT BILI-0.6
[**2169-8-13**] 04:55PM estGFR-Using this
[**2169-8-13**] 04:55PM GLUCOSE-498* UREA N-72* CREAT-13.2*
SODIUM-131* POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-19* ANION
GAP-23*
[**2169-8-13**] 07:32PM OTHER BODY FLUID WBC-2* RBC-0 POLYS-63*
LYMPHS-33* MONOS-4*
ADMISSION CXR:
FINDINGS:
Lung volumes are low. Right hemidiaphragm is elevated. Right
cardiac border is obscured by opacity, which may represent
atelectasis or pneumonia, if clinically appropriate. No pleural
effusions are seen. Hilar and mediastinal silhouettes are
stable. Mild cardiomegaly is noted, unchanged. No pneumothorax
is present. Mild pulmonary vascular congestion is seen. Patient
is status post median sternotomy. Sternotomy wires appear
intact. Bony structures appear unremarkable.
IMPRESSION:
1. Right middle lobe opacity, likely atelectasis or pneumonia,
if clinically appropriate.
2. Mild pulmonary vascular congestion.
ABDOMEN, SUPINE AND UPRIGHT: A catheter overlies the right mid
abdomen, compatible with a peritoneal dialysis catheter, and is
unchanged in appearance from prior study. There is a relative
paucity of bowel gas throughout, suggestive of fluid filled
small and large bowel loops, compatible with provided history of
watery stools. The stomach is visualized, and is not distended.
There is no free air or pneumatosis.
IMPRESSION: Relative paucity of bowel gas throughout, suggestive
of fluid filled small and large bowel loops, in keeping with
provided history of watery stools. Bowel distension is
difficult to assess given the lack of bowel gas.
[**2169-8-21**] MRI HEAD:
Acute infarcts involving the body of the corpus callosum,
cingulate gyrus, right occipital lobe, pons and left middle
cerebellar
peduncle. The involvement of multiple vascular territories
suggest emboli
from a central source in the appropriate clinical setting.
[**2169-8-21**] TTE:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast at rest. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild global
hypokinesis without regional dysfunction (LVEF 45%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No discrete vegetation or mass is seen. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No discrete vegetation or mass is seen. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Low normal biventricular systolic fuction. Aortic
valve sclerosis. No definite structural cardiac source of
embolism identified.
Compared with the prior study of [**2168-1-25**], global left ventricular
systolic function is slightly improved.
CLINICAL IMPLICATIONS:
Based on [**2165**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**2169-8-21**] OMENTUM BIOPSY PATHOLOGY:
Focal acute and chronic inflammation and focal fungal hyphal
forms with morphologic features consistent with aspergillus
species.
Blood cultures and CSF cultures were negative.
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 yo man with Type 1 diabetes on peritoneal
dialysis after a failed renal transplant. He was admitted with
abdominal pain and was found to have peritonitis with fungal
nodules in his omentum on ex-lap performed [**2169-8-18**]. These were
thought to be due to aspergillus, which was covered by
Amphotericin B. He was also empirically covered with
vancomycin, imipenem and flagyl.
His course was complicated by multiple brain emboli, likley
infectious, as well as uremia for which he underwent two
sessions of hemodialysis. TTE was negative for vegetations, but
there remained a high suspicion for fungal endocarditis. Given
the patient's continued clinical decline, however, he was made
CMO by his family on [**2169-8-23**] and passed on [**2169-8-24**] with his
brother at his bedside. Family declined an autopsy due to
religious beliefs.
Medications on Admission:
Medications (at home):
Prednisone 3 mg PO every other day
- Prednisone 5 mg PO every other day
- Doxercalciferol 2.5 mcg PO daily
- Metoprolol Tartrate 12.5 mg PO BID
[[- Lisinopril 2.5 mg PO daily ]]
- Fluoxetine 40 mg PO daily
- B Complex-Vitamin C-Folic Acid 1 mg PO daily
- Sevelamer Carbonate 2400 mg PO TID
- Protonix 40 mg, Delayed Release (E.C.) PO daily
- Epogen 5,000 unit injection once a week with dialysis
- Insulin Pump Reservoir
.
Medications on transfer:
CefTAZidime 1 g IV Q24H begin at 1800 on [**8-14**]
Fluoxetine 40 mg PO/NG DAILY
Morphine Sulfate 2-4 mg IV Q6H:PRN pain
Epoetin Alfa 4000 UNIT SC QMOWEFR with dialysis
Pantoprazole 40 mg PO Q24H
sevelamer CARBONATE 2400 mg PO TID W/MEALS
Nephrocaps 1 CAP PO DAILY
Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
Doxercalciferol 2.5 mcg PO DAILY
PredniSONE 5 mg PO/NG EVERY OTHER DAY alternating with 3 mg dose
PredniSONE 3 mg PO/NG EVERY OTHER DAY
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Fungal peritonitis
Multiple brain emboli, likely infectious
Chronic kidney disease
Renal tranplantation
Discharge Condition:
Patient expired at 12:15 pm with brother [**Name (NI) **] at bedside.
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 5856, 2761, 4280 | [
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train_8177 | completed | b4363f9d-7e5f-4c7b-9e29-75069cc2cae1 | Medical Text: Admission Date: [**2123-7-4**] Discharge Date: [**2123-7-28**]
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
AS, PAF
Major Surgical or Invasive Procedure:
[**7-16**] AVR, MVRepair, MAZE
History of Present Illness:
Patient is a 84 year old female with a history of PAF, HTN and
AS who presented to an OSH one day PTA with SOB and
palpitations. SHw was found to be in afib in the 150s. She was
transferred to [**Hospital1 18**] for cardiac catheterization and surgical
evaluation.
Past Medical History:
HTN
AF
s/p TAH [**2099**]
s/p right ORIF [**2121**]
AS
Social History:
retired
No tobacco
No Etoh
No IVDA
Family History:
Non contributory
Physical Exam:
On discharge:
Afebrile, BP 128/88, HR 89, AFib, 93% on RA
Irreg, irreg, no m/r/g
Lungs CTAB, min crackles
+1 BLE edema, some mottling (baseline), large ecchymotic area on
LUE
Neurologically grossly intact
Abdomin soft non tender and nondistended
Midsternal incision clean dry and intact
Pertinent Results:
[**2123-7-27**] 01:12AM BLOOD WBC-9.2 RBC-4.19* Hgb-12.7 Hct-37.4
MCV-89 MCH-30.4 MCHC-34.0 RDW-13.9 Plt Ct-215
[**2123-7-27**] 01:12AM BLOOD PT-16.3* INR(PT)-1.8
[**2123-7-27**] 01:12AM BLOOD Glucose-83 UreaN-30* Creat-0.9 Na-138
K-4.1 Cl-99 HCO3-31 AnGap-12
Brief Hospital Course:
An Echo done on [**7-5**] demonstrated AS with peak gradient 102,
mean gradient of 72, estimated valve area of 0.6cm2, 3+ MR, and
EF of 55%. Held coumadin in prep for cardiac cath, which she
received on [**7-7**], demonstrating AO valve area of 0.4 cm, peak
grad 50; CO/CI of 2.99/1.71 (3.63/2.99 with dobuta); RA 11; RV
38/10; PA 38/30; PCWP 24. LV gram with preserved Ef and inf
apical and mid ant-lat HK. Coronary angiogram revealed nl LMCA,
50-60% small diag off of lad and 40-50% rca without any flow
limiting dz.
After results of the cath were known, cardiothoracic surgery was
consulted for AVR/MVR surgery. She awaited preop workup, and
normalization of INR.
Post operatively she was transferred to the icu in critical but
stable condition on epi, milrinone, norepi, amio and propofol.
She was extubated on post op day 4, and her drips were weaned to
off by post op day 6, however she was placed on natrecor.
She was seen in consultation by electrophysiology for rate
control who recommended diltiazem beta blockade and amiodarone,
with follow up in 6 weeks for possible cardioversion.
She was given a 7 day course of vancomycin and levofloxacin for
sputum cultures positive for MRSA and gram negative rods.
She was HIT + without clinical signs and was anticoagulated with
coumadin already for her atrial fibbrilation.
Medications on Admission:
Digoxin, verapamil, lopressor, colace, levoxyl, coumadin(3 alt
with 4), lasix
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Pantoprazole Sodium 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*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*1 Inh* Refills:*2*
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Inh* Refills:*2*
11. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO once a
day for 1 doses: Please check INR on [**7-29**], and PRN.
Disp:*30 Tablet(s)* Refills:*0*
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Lifecare of [**Location 15289**]
Discharge Diagnosis:
AS, MR, Afib
PAF
CHF
HTN
Hypothyroid
s/p TAH
s/p hip and leg surgery
Discharge Condition:
Good.
Discharge Instructions:
No driving or lifting more than 10 pounds until follow up
appointment or while taking pain medication.
Call with temperature more than 100.5, redness or drainage from
incision, or weight gain greater than 2 pounds in 1 day or 5 in
1 week.
Shower, wash incision with mild soap and water and pat dry, no
lotions, creams or powders, no baths, keep covered when in the
sun.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 29478**] 1-2 weeks
Dr. [**Last Name (STitle) **] 1-2 weeks
Completed by:[**2123-7-28**]
ICD9 Codes: 5990, 4019, 2449 | [
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train_8182 | completed | 479e74e6-0f86-44c6-a6c2-db22bd53b93a | Medical Text: Admission Date: [**2101-10-4**] Discharge Date: [**2101-10-7**]
Date of Birth: [**2043-6-3**] Sex: F
Service: General Surgery
HISTORY OF PRESENT ILLNESS: This is a 58 year-old woman with
chronic pancreatitis, status post multiple abdominal
surgeries who presented disoriented. Her History of Present
Illness is obtained from her son. Apparently the patient was
in her usual state of health until five days prior to
presentation when she started having nausea and vomiting of
unclear frequency. She was also noted to have decreased
appetite and increased weakness to the point where she
couldn't ambulate with assistance. She was found to be short
of breath on the day of admission. Abdominal pain is unknown
and whether se was having gas or not was unknown. The
patient denies diarrhea, fever, chills, cough, urinary
symptoms, headaches, photophobia but due to this weakness is
brought to the operating room. In the Emergency Room she was
confused, was afebrile with a heart rate of 90 and blood
pressure of 110/70 initially. Her blood pressure then
dropped into the 70s and she was noted to have a very tender
abdomen. She was given 2 liters of fluid and started on a
Dopamine drip. She was admitted to the Medical Service in
the Intensive Care Unit.
PAST MEDICAL HISTORY: Includes [**Doctor Last Name 14837**] Roux-en-Y in [**2096**], a
laparoscopic cholecystectomy in [**2097**], a sphincterotomy in
[**2099**], splenectomy in [**2079**] secondary to motor vehicle
accident, an appendectomy, a right carotid endarterectomy in
[**2099**] and an aorto-[**Hospital1 **]-femoral graft placement which was
revised secondary to infection and replacement with an ex
[**Hospital1 **]-femoral. She also had chronic pancreatitis, coronary
artery disease with an ejection fraction of 45 percent, an
AICD placement in [**2100-1-13**], gastroesophageal reflux
disease, history of deep venous thrombosis in [**2096**],
hypercholesterolemia and migraines. Her medications at home
included Coumadin, Prilosec, Creon, Atenolol, Celebrex and
folic acid. She was an active smoker but denies alcohol.
FAMILY HISTORY: Her sister died of liver cancer and her
father died of an myocardial infarction at an unknown age.
On the evening of admission the medical Intensive Care Unit
staff consulted surgery for question of abdominal process.
When she was seen by surgery she was 99.5 with a heart rate
of 100, blood pressure of 70/21 on Dopamine at 10 and she was
markedly acidotic with a bicarbonate of 15 and a base deficit
of 7. She was awake but confused. Her abdomen was soft,
distended and diffusely tender, left greater than right side.
She had perfusion tenderness and guarding and she had gross
blood and stool in the rectal vault. Her white count is
16.6. Her hematocrit had fallen from 30 to 28, platelets
268. Her PT was 22.5, PTT 63 and INR of 3.5. Chem-7
135/4.0, 100/16, 11/1.1 and 58. Her urinalysis was positive
for nitrites, had 11 to 20 white cells and many bacteria.
Her ALT was 21, AST 59, alk phos 291 and total bilirubin .6
and amylase of 11, lipase of 16 and lactate level of 3.2.
Her CK was 966. She underwent an abdominal CT which showed
portal venous air and apparently a right colon that was
thickened mid transverse colon consistent with colonic
ischemia. She also had pneumatosis. She was therefore
diagnosed with likely dead bowel and taken to the operating
room where she underwent exploratory laparotomy and found to
have dense adhesions and a frankly necrotic sigmoid and
proximal rectum. She underwent left sigmoid resection and
transverse colostomy and underwent extensive lysis of
adhesions. She was then admitted to the Surgical Intensive
Care Unit in critical condition.
She was initially maintained on a Levophed drip and received
4 units of packed cells and 4 of fresh frozen plasma over her
first day. She was given Levophed and Flagyl for
antibiotics. She was maintained with extreme acidosis with
base deficit in the 10 - 11 range. On postoperative day one
her platelets fell to 28 and her abdomen was very distended
with drains pouring out serosanguinous fluid. A bladder
pressure was obtained with a question of abdominal
compartment syndrome. This was found to be 19 and at that
time she had systolic blood pressure of 119 so no further
treatment was required for that. By postoperative day two
she had deteriorated and required a change of pressors from
Levophed to dobutamine secondary to a low cardiac index. She
was also placed on Pitressin with these maintaining her blood
pressure in the 80/60 range.
Her next problem area was oxygenation with worsening
oxygenation over the night and a low pO2 of 36 with
improvement of pO2 in the 50's on pressure control once she
was paralyzed and sedated. She received 8 more units of
fresh frozen plasma over the night of postoperative day
number two to treat elevated coags. Discussion was
undertaken on postoperative day number two with her sons
given her worsening clinical status, her worsening acidosis.
At this point her lactate was 17 and her sons made it clear
that they did not want to continue treatment and elected for
comfort measures only status when the pressors were
withdrawn. The patient died quickly.
DISPOSITION: Death.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2101-10-7**] 12:55
T: [**2101-10-11**] 14:44
JOB#: [**Job Number 14838**]
ICD9 Codes: 5849, 4019, 2720 | [
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train_8183 | completed | a776e119-a899-4bb0-9a86-788b90dc25df | Medical Text: Admission Date: [**2163-3-5**] Discharge Date: [**2163-3-9**]
Date of Birth: [**2163-3-5**] Sex: M
Service: NB
DISCHARGE DIAGNOSIS: Premature twin A, 33 weeks gestation.
HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 59015**] is the [**2068**]-gram
product of a 33-week IVF-twin gestation born to a 41-year-old
gravida 3, para 1 now 2, living 3 female. Her prenatal
screens revealed she is O positive, hepatitis B surface
antigen negative, RPR nonreactive, rubella immune, and group
B Strep status was unknown. Pregnancy was otherwise
unremarkable.
Because of preterm labor, mom was allowed to deliver. She
delivered twin A by spontaneous vaginal delivery with Apgars
of 9 and 9. Twin had to be delivered by cesarean section
for transverse lie.
Infant was admitted to the [**Hospital3 **] Special Care Nursery.
PHYSICAL EXAMINATION ON ADMISSION: Physical exam on
admission revealed a pink, active infant in room air, and no
murmur heard. Blood cultures and CBC were sent. Dextrostick
62.
PROBLEMS DURING HOSPITAL STAY: Respiratory: Infant remained
in room air throughout the hospital course with a rare
episode of apnea and bradycardia of prematurity.
Cardiac: There were no cardiac issues.
Infectious disease: Infant had initial CBC with a WBC count
of 9.6, 16 polys, 0 bands, and 68 lymphocytes with 298
platelets and 57.8 hematocrit. Ampicillin and gentamicin
were begun, and at 48 hours with negative cultures, the
antibiotics were discontinued.
Feeding and nutrition: At the time of transfer, the infant
is on 100 cc/kg of mother's milk, Special Care 20, mostly pg,
but occasional p.o. partial feedings. His weight at the time
of transfer was grams.
Hematologic: Initial hematocrit was 57.8. His initial
bilirubin on [**3-8**] was 8.5 and on [**3-9**] was
Parents would like the babies to be transferred closer to
home, and for this reason, they are being moved to [**Hospital3 **]. They will be in the care of Dr. [**Last Name (STitle) 59016**] on the Special
Care Nursery.
Upon discharge, they will be followed up at [**Hospital1 **]
[**Hospital1 3494**] Center by Dr. [**Last Name (STitle) 59017**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 50-393
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2163-3-8**] 09:45:50
T: [**2163-3-8**] 10:10:06
Job#: [**Job Number 59018**]
ICD9 Codes: V290 | [
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] | [
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train_10511 | completed | 23399c2c-33c6-4b6f-8abc-d3d7294ed14f | Medical Text: Admission Date: [**2166-4-30**] Discharge Date: [**2166-5-10**]
Date of Birth: [**2108-3-2**] Sex: F
Service:
ADMITTING DIAGNOSIS: Adenoid cystocarcinoma of the carina.
HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient
is a delightful 58-year-old woman, who presented with
bilateral pneumonia and was found to have an obstructive
tumor of the carina.
We took her to the operating room and debulked the tumor, and
sent it off for pathological analysis. The path came back as
adenoid cystocarcinoma of the carina. After at least six
week period of pulmonary rehabilitation, she was rescanned,
and found to have no evidence of metastasis. We took her to
the operating room, and performed a mediastinoscopy to
mobilize the pretracheal plane, and found no evidence of
mediastinal adenopathy in the paratracheal region. There is
also no evidence of invasion of the pulmonary artery.
We therefore, performed a right thoracotomy and a carinal
resection with primary reconstruction. She did well, and was
maintained in the Intensive Care Unit for several days. She
was then sent to the floor, where she underwent a flexible
bronchoscopy by Dr. [**First Name (STitle) **] [**Name (STitle) **] on postoperative day #7.
This revealed a nicely reconstructed trachea and carina.
After keeping her in the hospital for a few more days, she
was discharged in excellent condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern4) 9931**]
MEDQUIST36
D: [**2166-8-7**] 18:35
T: [**2166-8-11**] 08:35
JOB#: [**Job Number 12890**]
ICD9 Codes: 2449 | [
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train_10681 | completed | cbca0609-3cdb-4b16-a49a-76f095b47324 | Medical Text: Admission Date: [**2113-3-4**] Discharge Date: [**2113-3-14**]
Date of Birth: [**2041-9-27**] Sex: M
Service:
ADDENDUM
The patient is status post coronary artery bypass graft on
[**3-7**].
DISCHARGE MEDICATIONS:
1. Percocet one to two tabs p.o. p.r.n. q 4 to 6 h.
2. Colace 100 mg p.o. b.i.d.
3. Lasix 40 mg p.o. b.i.d.
4. KCL 20 mEq p.o. b.i.d. for one week
5. Lopressor 12.5 mg p.o. b.i.d.
6. Aspirin 325 mg p.o. b.i.d.
7. Amiodarone 400 mg p.o. three times a day times five
days. 400 mg p.o. b.i.d. times one week and after that
400 mg p.o. q day.
The patient is being discharged to rehabilitation. The
patient stayed because he had another episode of V-tach on
[**2113-3-12**] and it was felt patient would benefit from additional
hospital observation. The patient felt dizzy and lightheaded
and was desating while working with physical therapy and
required assistance with walking. The patient was started on
Amiodarone prophylactically to enhance strength in the dose
as described above. The patient is still to follow-up with
EPS. EPS was contact[**Name (NI) **] and they plan to put in ICD siting
the cardiogram with normal function. They agreed to follow
him up on their own within a month.
The patient upon discharge is stable.
DR.[**Last Name (STitle) **],[**Known firstname 275**] 02-248
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2113-3-13**] 21:35
T: [**2113-3-13**] 22:53
JOB#: [**Job Number 38152**]
ICD9 Codes: 4111, 4275, 4271, 4019 | [
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train_15537 | completed | f9388dc1-5ae9-4346-aa82-671ba290e277 | Medical Text: Admission Date: [**2149-12-10**] Discharge Date: [**2149-12-15**]
Date of Birth: [**2067-12-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
History obtained from pt, pt's son, and [**Name (NI) **] records. This is a 81
yo F with a history of mild dementia and HTN who presents with
AMS. Pt had been recently been evaluated at [**Hospital1 2025**] for a facial
rash that was reportedly diagnosed as herpes zoster and started
on course of valtrex this past Saturday. Per son, rash was first
noted on Saturday, but may have been present even prior to
Saturday. She was also evaluated at Mass Eye & Ear where there
was reportedly no evidence of herpes invovlement of the eye. She
was given an eyedrop (?benzamine per son)but did not take it as
she lost the bottle. Pt denies any facial pain, blurry vision,
painful right eye, fevers, headache, or confusion. She also
denies any further rash, urinary frequency, changes in amount of
urination, dysuria, diarrhea, abdominal pain, nausea, vomiting,
and flank pain. Reports good po intake. Her mental status
continued to deteriorate to the point that the pt's sister was
reportedly called by pt's elder housing apt that she was found
her on the floor grabbing at things in the air and not making
sense. There was also report from the ED of possible diarrhea,
which the son and the pt are not aware of. She was then
transported to the ED.
.
In the ED, Tm 97.6, BP 150/70, HR 101, RR 18, O2 sat 99% RA.
Labs notable for WBC 20.5 without associated bandemia, Cr 4.5
(prior b/l 0.6 - 0.8), BUN 58, K 4.3, HCO3 20, lactate 1.6. UA
floridly positive. LP performed with 5 WBC, 2 RBC, 0 polys, 92
lymphs, protein 35, glucose 107. NCHCT without acute pathology,
CT abd/pelvis without hydronephrosis, intra-abdominal abscesses,
signs of pyelo but exam limited as no IV contrast given. Given
vancomycin 1 gm IV X 1, ceftriaxone 1 gm IV X 1, acylovir 550 mg
IV X 1 and 2L IVFs. Admitted to [**Hospital Unit Name 153**] for further management.
.
ROS: As above. Otherwise pt denies any focal weakness, cough,
shortness of breath, chest pain, constipation, melena, BRBPR.
.
Past Medical History:
Dementia - mild per note in OMR from [**9-24**]
HTN
h/o uterine fibroids
Social History:
Lives in elderly independent living facility where sister also
lives. No prior h/o tobacco, EtOH per OMR notes.
Family History:
NC
Physical Exam:
Vitals: T: 98.2 BP: 132/86 HR: 103 RR: 20 O2Sat: 98% RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: PERRL, sclera anicteric, no hyperemia or conjuncitivitis
noted but left eyelid closed. Slight crust. No epistaxis or
rhinorrhea, MMM, OP Clear, crusted vesicular appearing rash with
erythematous base over left side of forehead, upper eyelid in V1
distribution of trigeminal nerve. Slight crust noted right of
midline on forehead. Negative Brudzinski's, Kernig's, no
meningmus appreciated.
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
BACK: positive minimal b/l CVAT; however pt also reports
tenderness when palpating upper and lower lateral back
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, WWP
NEURO: alert, oriented to person. Answers "[**2128**]" to month and
year, does not know where she is. unable to fully assess EOMI
but otherwise CN appear intact. Moves all 4 extremities.
Strength 5/5 in upper and lower extremities. Plantar reflex
downgoing. gait not tested.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
URINE CULTURE (Final [**2149-12-11**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2149-12-10**] 02:35PM GLUCOSE-221* UREA N-61* CREAT-4.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-17* ANION GAP-20
[**2149-12-10**] 08:19AM URINE HOURS-RANDOM UREA N-128 CREAT-107
SODIUM-70 POTASSIUM-30
[**2149-12-10**] 08:19AM URINE OSMOLAL-257
[**2149-12-10**] 02:34AM GLUCOSE-175* UREA N-59* CREAT-4.8* SODIUM-134
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-17* ANION GAP-18
[**2149-12-10**] 02:34AM CALCIUM-8.1* PHOSPHATE-5.1* MAGNESIUM-2.3
[**2149-12-10**] 02:34AM WBC-19.8* RBC-4.43 HGB-14.2 HCT-37.4 MCV-84
MCH-32.0 MCHC-37.9* RDW-13.1
[**2149-12-10**] 02:34AM PLT COUNT-311
[**2149-12-9**] 11:00PM CEREBROSPINAL FLUID (CSF) PROTEIN-35
GLUCOSE-107
[**2149-12-9**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-2* POLYS-0
LYMPHS-92 MONOS-8
[**2149-12-9**] 11:00PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-116*
POLYS-2 LYMPHS-89 MONOS-9
[**2149-12-9**] 09:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.016
[**2149-12-9**] 09:00PM URINE RBC-[**2-19**]* WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2149-12-9**] 08:54PM GLUCOSE-168* UREA N-58* CREAT-4.5*#
SODIUM-135 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-20* ANION GAP-22*
[**2149-12-9**] 08:54PM estGFR-Using this
[**2149-12-9**] 08:54PM WBC-20.5* RBC-4.85 HGB-15.2 HCT-41.7 MCV-86
MCH-31.4 MCHC-36.5* RDW-13.1
.
CT Torso:
TECHNIQUE: Multidetector helical scanning of the abdomen and
pelvis was
performed without oral or intravenous contrast due to the
patient's acute
renal failure. Coronal and sagittal reformats were displayed.
NON-CONTRAST CT OF THE ABDOMEN: There is a 20-mm low-density
lesion within
segment VIII/VII of the liver (3:16), which is nonspecific and
cannot be
further evaluated on this non-contrast CT. Sludge layers within
the
gallbladder. The adrenal glands, spleen, and intra-abdominal
small and large
bowel loops are normal. The pancreas is fatty replaced, with
calcifications
within the tail. There are 3 prominent mesenteric lymph nodes,
measuring up
to 16 mm in short axis. There is a tiny high- density focus
within the lower
pole of the right kidney which may represent milk of calcium or
a
prominent papilla. There are no definite renal calculi and no
calculi seen
along the courses of the ureters bilaterally. No hydronephrosis.
Exam for
renal abscess is limited due to lack of IV contrast. However,
there are no
secondary signs, such as contour abnormality or perinephric
stranding. There
is a 16 mm simple cyst arising from the lower pole of the left
kidney with
sparse calcifications. The aorta is of normal caliber.
CT OF THE PELVIS: Foley catheter is seen within a decompressed
bladder. The
sigmoid colon and rectum are normal. There is no free fluid or
lymphadenopathy.
There are no bone findings of malignancy. Very mild
anterolisthesis of L5 on
S1 is noted. There is also a hemangioma replacing the L1
vertebral body.
IMPRESSION:
1. No evidence of renal or ureteral calculi and no
hydronephrosis. Evaluation
of the renal abscesses is limited due to lack of IV contrast,
however, there
are no secondary signs of renal abscess. No intra-abdominal
abscess.
2. 18 mm hypoattenuating lesion within the liver is difficult to
characterize
in this non-contrast CT. Diagnostic considerations include a
cyst or small
abscess, for which ultrasound is recommended on a non-emergent
basis.
3. Gallbladder sludge, without CT evidence of cholecystitis.
4. Left renal cystic lesion with sparse calcification - a 6
month follow-up
ultrasound is recommended.
Brief Hospital Course:
81 yo F with a history of mild dementia, recent diagnosis of
herpes zoster V1 distribution, and HTN who presented with
delerium.
.
# Altered mental status: Pt had been recently been evaluated at
[**Hospital1 2025**] for a facial rash that was reportedly diagnosed as herpes
zoster and started on course of valtrex 5 days prior to
admission. Admission labs notable for WBC 20.5 without
associated bandemia. She was in acute renal failure up to
Creatinine of 4.5 from baseline of 0.8. UA floridly positive
c/w UTI. LP performed with 5 WBC, 2 RBC, 0 polys, 92 lymphs,
protein 35, glucose 107. Head CT without acute pathology, CT
abd/pelvis without hydronephrosis, intra-abdominal abscesses,
signs of pyelo but exam limited as no IV contrast given. Given
vancomycin 1 gm IV X 1, ceftriaxone 1 gm IV X 1, acylovir 550 mg
IV X 1 and 2L IVFs. Admitted to [**Hospital Unit Name 153**] for further management.
While in the ICU, the pt was continued on cipro to cover for UTI
and IV acyclovir to cover for potential HSV/VZV meningitis. Her
mental status gradually improved with resolution of her ARF and
treatment of her UTI as per below. She was continued on her
galantamine for her dementia. The IV acyclovir was continued
until CSF PCR was negative for VZV, and pt pulled out her IV's
before results were back for HSV PCR. GIven low clinical
likelihood of HSV meningitis and benign CSF, pt was transitioned
back to po acyclovir to avoid agitation with IVs/lines. Pt was
discharged back on valtrex to complete a 2 week course for
facial zoster. Prior to discharge, HSV PCR came back negative.
She was instructed to maintain hydration while taking her
valtrex so as not to have recurrent renal failure. Per her son,
she was 75-80% back to her baseline mental status at time of
discharge. Of note, as stated, she did have one night of
sundowning and pulling out her IVs.
.
# Sepsis due to E Coli UTI/Urinary tract infection: Grew
pansensitive E Coli. Started on antibiotics on [**12-10**]. Treated
with 5 day course of cipro.
.
# Acute renal failure: Baseline Cr 0.6 - 0.8 with most recent Cr
in [**9-24**] 0.8. Cr peaked at 4.3, likely due to septicemia vs.
medication effect from acyclovir. Renal was consulted and
recommended boluses of NS prior to acyclovir administration. Her
ace inhibitor was held. Her creatinine slowly improved back to
baseline. Her benzapril will be held until follow up with her
PCP and completion of her valtrex course. Pt will be discharged
with instructions to maintain good hydration while completing
valtrex.
.
# Facial herpes zoster: Involvement in V1. No hyperemia of eye
noted and pt denies any blurry vision or eye pain. Pt had
already been seen by optho at [**Hospital1 2025**] and had no visual complaints
while here. She had received 5 days of valtrex prior to
admission, then IV acyclovir initially here (to cover for
potential VZV/HSV meningitis), and then converted back to
valtrex to complete 14 day course of antivirals. Pt will need to
follow up with optho as an outpatient.
.
# L renal cyst: 6 month f/u u/s recommended
.
# Liver lesion: 18 mm hypoattenuating lesion within the liver is
difficult to characterize on non-contrast CT. Diagnostic
considerations include a cyst or small abscess, for which
ultrasound is recommended on a non-emergent basis
.
# Dementia: Reportedly mild at baseline. Seen by PT, and concern
for home safety given recall 0/3, oriented to self only. Per pts
son, she has never had issues with wandering off or using the
stove. Has been taking her own medications and son sets her pill
box up each week. Meals are prepared at her living facility and
pt has daily activities she goes to. As of discharge son felt pt
was back to 75% of her baseline. Per son, pt is performing her
ADLs (with the exception sometimes of washing) and taking her
medications on her own. We discussed that in the near future she
may need higher level care, such as [**Hospital3 **], but son
would like to try home [**Name (NI) 269**] first as the pt has many friends at
her independent living. SHe was continued on her galantamine.
.
# HTN: Continued norvasc. Benzapril was held in the setting of
acute renal failure, likely from acyclovir. Held benzapril 20 mg
daily given recent ARF and receiving valtrex still. BP
controlled here on just norvasc alone.
.
# Diabetes Mellitus Type II, uncontrolled, no complications: New
diagnosis. HgbA1c 6.2. Fasting glucose up to 140s on a daily
basis. Will discharge on metformin 500 mg in the morning, which
can be increased to twice daily if pt is tolerating it. Son
asked to advise her independent living to change her meals to
diabetic diet (meals prepared for pt at her living facility).
Pt has had elevated levels of glucose. She carries no diagnosis
of diabetes. It is
Medications on Admission:
Valtrex 1 gram tid
? Benzanine eye drops
Amlodipine/Benazepril 5/20 mg daily
Galantamine 16 mg daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Galantamine 4 mg Tablet Sig: Four (4) Tablet PO once a day.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-18**]
Drops Ophthalmic PRN (as needed).
4. Valtrex 1 g Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO each morning.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Urinary tract infection
E Coli septicemia
Acute renal failure
Herpes Zoster
Delerium
Diabetes Mellitus Type II
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a urinary tract infection and confusion.
You were treated with IV antivirals for the herpes zoster on
your face, as well as antibiotics for your urinary tract
infection. You also had kidney failure felt to be due to
medications you were on. Your kidney function has now
normalized.
.
You should continue to take your valtrex for the time designated
on your prescription. Your benzapril has been discontinued until
you follow up with your primary care doctor. It is very
important you drink plenty of fluids while you are taking the
valtrex, as you can get kidney failure again if you do not.
.
You were diagnosed with diabetes. You will need to comply with a
diabetic diet and you were started on a medication called
metformin. This medication can cause nausea and diarrhea, but
often gets better over time. We started you on a low dose, only
once a day.
.
You will need to have an ultrasound of your kidneys in 6 months
to futher follow up a cyst. You also will need an ultrasound of
your liver to further delineate a small lesion noted on the
liver on CT scan. This should be discussed with your primary
care doctor at your next visit.
.
Call your doctor or return to the ER for worsening confusion,
pain with urination, dehydration, visual changes or pain, facial
pain, chest pain, or any other concerning symptoms.
Followup Instructions:
1. Please follow up with Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 131**] on [**12-23**] at 9:45
AM (covering for Dr. [**Last Name (STitle) 172**]. Located in the same office as Dr.
[**Last Name (STitle) 172**]. Phone [**Telephone/Fax (1) 133**]
.
2. Please follow up with your eye doctor in the next week.
ICD9 Codes: 5849, 5990, 4019 | [
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train_15592 | completed | 7e503ca8-66c5-4eae-aa60-01ec39d1a528 | Medical Text: Admission Date: [**2105-4-30**] Discharge Date: [**2105-5-6**]
Service:
ADDENDUM: Prior to discharge the patient was ambulated. She
continued to desat to 89% on room air while ambulatory. It
was recommended that she be discharged home on 2 to 3 liters
of home oxygen. The patient's family continued to wish her
to go home. They will consider outpatient pulmonary rehab.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2105-5-6**] 01:24
T: [**2105-5-6**] 13:31
JOB#: [**Job Number 100501**]
ICD9 Codes: 486, 2762 | [
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train_15116 | completed | b2a765bc-4e5e-4636-a523-7ba24bb3ecfa | Medical Text: Admission Date: [**2149-12-31**] Discharge Date: [**2150-1-5**]
Date of Birth: [**2104-6-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Ventricular fibrillation arrest
Major Surgical or Invasive Procedure:
Central line placement
Cardiac cath
History of Present Illness:
45M with a history of MI s/p BMS to RCA 10 years ago is admitted
s/p witnessed cardiac arrest. According to the report, he
collapsed while at work, a bystander found him breathing with a
bleeding laceration to his right forehead and initiated CPR x 20
minutes until EMS arrived, placed an AED, which delivered a
single shock. He received another 40 minutes of compressions and
atropine 1mg, epinephrine 1mg and lidocaine 100mg while
intransit to [**Hospital 4199**] hospital.
.
According to the report, on arrival to Widdham, he was in PEA,
he was treated with epinephrine 1mg x 3, Atropine 1mg x2, and
Amiodarone 300mg and converted to VF, he was cardioverted x 3
and re-entered PEA. He was treated with narcan 2mg, another
epinephrine 1mg x 4 amiodarone 150mg, and re-entered VF and was
cardioverted 2x after which return of spontaneous circulation
was noted. He was started on a amiodarone, heparin and dopamine
drips. In total, he received CPR for 48 minutes at Widdham with
possibly another 60 minutes of CPR in the field. Cooling
protocol was initiated and he was transfered to [**Hospital1 18**] for
evaluation and further management. Fixed and dialated pupils
were noted prior to transfer. On transfer, his vitals were
Temp:95, P:136 BP:94/58, rhythm strip showed afib with RVR.
.
On arrival to the ED, his vitals were: T:91.9 P:121 BP:117/84.
Initial EKG showed Atrial fibrillation with ventricular rate of
126BPM, STE in V4-5 STD II, III, aVF, q waves in II, III, aVF.
In comparison to the EKG from [**2139**], q waves are unchanged,
STD/STE are new. He was successfully cardioverted to sinus
rhythm. Repeat EKG showed improvement in STE/STD with decreased
ventricular rate. CT head showed no acute process, CTA chest
showed emphysematous blebs and no PE. He was admitted to the
CCU.
.
On admission to the CCU, his vitals were BP 123/94, P:83, 100%
on vent settings of 500/12/5 PEEP FIO2 0.5. He was taken to the
cath lab, which showed chronically occluded RCA and LAD with a
patent LCX. Given chronicity of lesions, no intervention was
performed. Ischemic cardiomyopath likely VT/VF arrest. After
cardiac cath patient entered sinus tachycardia and was given
metoprolol leading to hypotension and return of atrial
fibrillation, he was again cardioverted to sinus rhythm. Given
furosemide with appropirate urine output.
.
On discussion with the family, patient has not sought medical
care in the last 9 1/2 years. Following his cardiac cath in
[**2139**], patient was compliant with aspirin, plavix, atenolol,
lisinopril, and lipitor for roughly 6 months after which he
discontinued all medications except Aspirin 81mg and nitro PRN
which he has not taken recently. Accodording to the wife, he has
had long standing dyspnea on exertion, worse in the winter
months. She notes that he does not complain of orthopnea, PND,
palpatations. She reports that he has never had loss of
consciousness.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS:
--[**2139**] BMS x1 to RCA, cath showing 100% stenosis of mid LAD
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- Hyperlipidemia
- [**Year (4 digits) 30680**]
Social History:
- Tobacco history: 2ppd x 29 years (58 pack years)
- ETOH: 1-2 drinks / month
- Illicit drugs: none
Family History:
- Mother: Hypertension, hyperlipidemia, "silent" MI on EKG noted
early 50's
- Father: [**Name (NI) 30680**], first MI at 65
- Maternal GF: CAD 70
- Maternal uncle first MI [**87**]
- Maternal Cousin (female): 46 first MI
- Paternal GF: CAD
Physical Exam:
On admission
GENERAL: Middle aged male intubated, sedated, C-collar in place.
HEENT: 3cm laceration to right brow, sutures in place. Pupils
5mm and not reactive to light. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa.
NECK: C- collar in place, JVP not assessed
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: CTABL, no rales, wheezes or rhonchi.
ABDOMEN: Soft, ND, Bowelsounds absent
EXTREMITIES: Cool to the touch. Motteling and palor of toes BL,
ashen lower extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP: 0 not dopperable PT: 0 not dopperable
Left: DP: dopplerable PT: 0 not dopperable
Access: Right radial sheath, Right femoral a/v sheaths, Left
femoral VL Left radial A-line.
Pertinent Results:
On Admission:
[**2149-12-31**] 03:30PM BLOOD WBC-19.8* RBC-5.03 Hgb-15.1 Hct-45.8
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.0 Plt Ct-228
[**2149-12-31**] 03:30PM BLOOD PT-15.0* PTT-29.5 INR(PT)-1.3*
[**2149-12-31**] 03:30PM BLOOD Glucose-289* UreaN-11 Creat-1.0 Na-141
K-4.6 Cl-108 HCO3-20* AnGap-18
[**2149-12-31**] 03:30PM BLOOD ALT-240* AST-201* LD(LDH)-572*
CK(CPK)-1093* AlkPhos-60 TotBili-0.3
[**2149-12-31**] 03:30PM BLOOD Lipase-21
[**2149-12-31**] 03:30PM BLOOD cTropnT-0.85*
[**2149-12-31**] 03:30PM BLOOD CK-MB-59* MB Indx-5.4
[**2149-12-31**] 03:30PM BLOOD Albumin-3.3* Calcium-6.4* Phos-4.5 Mg-2.0
[**2149-12-31**] 04:24PM BLOOD %HbA1c-5.7 eAG-117
[**2149-12-31**] 03:30PM BLOOD TSH-1.4
[**2149-12-31**] 07:38PM BLOOD Type-ART Rates-/20 Tidal V-550 FiO2-100
pO2-378* pCO2-28* pH-7.28* calTCO2-14* Base XS--11 AADO2-307 REQ
O2-57 -ASSIST/CON Intubat-INTUBATED
[**2149-12-31**] 06:42PM BLOOD Lactate-3.0*
=
=
========================IMAGING=================================
CT CHEST (performed at OSH,[**2149-12-31**] read by [**Hospital1 18**])
The patient is intubated, with the ET tube terminating within
the distal
trachea. A transesophageal catheter terminates within the
stomach with the
side port at the GE junction.
.
Multiple large blebs are seen throughout both lungs,
predominantly in the
upper zones. There is neighboring interstitial fibrosis.
Moderate dependent atelectasis is seen with enhancement
throughout most of the parenchyma, although there are pockets of
hypoperfusion which may signify an early infectious process
(5:118). No pneumothorax is seen. The great vessels are patent
and normal in caliber. No pulmonary embolism is detected to the
subsegmental levels.
.
The heart size is normal. There is no pericardial effusion.
There is no
effusion or pulmonary edema.
.
Included views of the upper abdomen demonstrate a
normal-appearing liver,
stomach, spleen, and left adrenal gland.
.
OSSEOUS STRUCTURES: There is no acute fracture or dislocation.
No concerning
blastic or lytic lesions are detected.
.
IMPRESSION:
1. Multiple large blebs in a panlobar pattern, raising suspicion
for alpha-1 anti-trypsin deficiency.
2. Moderate dependent atelectasis with pockets of hypoperfused
lung
parenchyma, raising the possibility of early infection or
aspiration.
3. No PE detected to the subsegmental levels.
.
CT HEAD (performed at OSH,[**2149-12-31**] read by [**Hospital1 18**]):
FINDINGS: There is no evidence of acute intracranial hemorrhage,
edema, mass, mass effect, or large vascular territorial
infarction. The ventricles and sulci are normal in
configuration. No acute fracture is seen. A small mucous
retention cyst is present within the right maxillary sinus.
There is mucosal thickening seen within the sphenoid sinuses,
greater on the right. The middle ear cavities and mastoid air
cells are clear.
.
IMPRESSION:
1. No acute intracranial process.
2. Mild sinus disease.
.
ECHO [**2150-1-1**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is an apical left
ventricular aneurysm. Overall left ventricular systolic function
is severely depressed (LVEF= 25 %) secondary to multiple focal
wall motion abnormalities including extensive apical akinesis
with focal dyskinesis. Right ventricular chamber size is normal.
There is focal hypokinesis of the apical free wall of the right
ventricle. The aortic root is mildly dilated at the sinus level.
The aortic valve is not well seen. There is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
At time of expiration:
[**2150-1-4**] 03:35AM BLOOD WBC-9.1 RBC-3.84* Hgb-11.3* Hct-32.5*
MCV-85 MCH-29.3 MCHC-34.6 RDW-14.4 Plt Ct-136*
[**2150-1-4**] 03:35AM BLOOD PT-13.3 PTT-53.1* INR(PT)-1.1
[**2150-1-4**] 03:35AM BLOOD Glucose-118* UreaN-13 Creat-0.6 Na-135
K-4.0 Cl-103 HCO3-26 AnGap-10
[**2150-1-4**] 03:35AM BLOOD ALT-99* AST-281* AlkPhos-43 TotBili-0.5
[**2150-1-4**] 03:35AM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.8*
Mg-2.3
[**2150-1-4**] 03:35AM BLOOD Phenyto-10.7
[**2150-1-4**] 03:56AM BLOOD Type-ART pO2-168* pCO2-43 pH-7.44
calTCO2-30 Base XS-5
[**2150-1-4**] 03:56AM BLOOD Lactate-1.0
Brief Hospital Course:
A 45 yoM with PMH Smoking, HTN, HL, CAD s/p BMS to RCX with poor
medical follow up was is transfered s/p Ventricular fibrillation
arrest for cooling protocol.
.
Neurological: Prior to arrival at [**Hospital1 18**], patient was
resuscitated with ACLS for 108 minutes. Per family, patient was
seen on security camera after collapse and was down for 8
minutes prior to the initiation of CPR. Arctic sun protocol was
initiated <6 hours post arrest. Neurologic examination on
admission was notible for fixed and dilated pupils, and absent
corneal reflex. CT head is negative for acute process. After 24
hours, patient was re-warmed and sedation was held. Off
sedation, patient remained unresponsive and was noted to have
clinical signs of seizure. EEG showed status epilepticus,
patient was loaded with keppra followed by dilantin with fair
control of seizure activity. EEG also showed GPEDS pattern which
is associated with high mortality. After a 48 hour period off
sedation, seizure activity increased. A family meeting was held
in which the poor prognosis was discussed and his care was
transitioned to comfort measures only with both the patient's
wife and son in agreement. He expired approximately 8 hours
after extubation with family at bedside. Autopsy was declined by
the family and not referred to the CME.
# CORONARIES: Patient underwent cardioversion in the field and
in PEA arrest at [**Hospital 21242**] hospital where ACLS was continued. He
was successfully resuscitated, intubated, placed on amiodarone
drip, pressors, sedation, and anticoagulation and transferred to
[**Hospital1 18**] for further management. In the ED he was noted to be in
afib with RVR, lateral STEMI. Echo performed at bedside showing
global hypokinesis with anterior, anteroseptal, lateral, and
apical wall motion abnormalities. Admission EKG showed rate
dependent STE elevations likely related to demand ischemia.
Cardiac cath showed old RCX and LAD lesions with patent LCX.
Given chronicity of lesions, no intervention was performed. VF
arrest is likely a result of arrythmagenic focus of infarcted
myocardium.
.
# RHYTHM: Initially in Afib with RVR in the ED. DCCV in the ED
with reuturn to sinus rhythm. Throughout remainder of
hospitalization, patient remained in sinus rhythm.
.
#: GI bleed: On admission, patient was noted to have sanguanous
return from OGT. HCT remained stable throughout hospitalization
and transfusion was not necesary. Stress ulcer is likely
etiology.
.
# Head trauma: Skin laceration on right brow noted by EMS at
time of arrest, likely post traumatic after syncope. Head CT
negative however C-collar could not be cleared without MRI given
neurologic dysfunction.
.
# CHF: Last echo in [**2139**] showed LVEF 40-45%, ECHO peformed on
admission showed severely depressed (LVEF= 25 %) secondary to
multiple focal wall motion abnormalities including extensive
apical akinesis with focal dyskinesis. According to the family,
the patient did not experience congestive heart failure
symptoms.
.
# Resarch: patient consented to participate in corticosteroid in
myocardial infarction study. He was randomized to receive
Hydrocortisone 100mg IV Q8H or placebo x7 days.
.
COMM: Wife [**Name (NI) 1439**] (HCP) (h)[**Telephone/Fax (1) 30681**] (c)[**Telephone/Fax (1) 30682**]
Medications on Admission:
Aspirin 81mg daily
Nitro sublingual PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Anoxic brain injury
2. Cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 5789, 4168, 4280, 3051, 4275, 412, 4019, 2724 | [
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train_15136 | completed | bb227a97-5286-43f3-8a1a-9ac0b3f87a9b | Medical Text: Admission Date: [**2128-6-22**] Discharge Date: [**2128-7-5**]
Date of Birth: [**2072-9-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Fever, fatigue, hypotension
Major Surgical or Invasive Procedure:
Hemodialysis catheter exchange
History of Present Illness:
This is a 55 year-old female with a history of ESRD secondary to
hypertensive nephropathy, on HD and PD, who presents with 2
weeks of fatigue, uncontrolled hypertension, and new gram
negative bacteremia. She was found to have discharge from
tunneled HD catheter exit site on [**6-21**] and blood cultures and
swab were sent. Blood cultures returned 2/2 bottles gram
negative rods, and patient was referred by outpatient
nephrologist to [**Hospital1 18**] ED for further evaluation, where she was
found to have blood pressure markedly elevated from baseline.
She reports she has not taken her blood pressure medications for
past 4 days because she ran out and was waiting for refills. She
denies any chest discomfort other than her chronic breast pain
that is related to swelling and erythema. She has had occasional
headache, but no vision disturbance. She also reports that she
has been doing fewer cycles of her peritoneal dialysis over the
past few days.
.
The patient reports subjective fevers, with temperature at home
in high 99s. She also reports decreased appetite over past 2
weeks. She denies any nausea, vomitting, or abdominal pain. She
denies cloudy peritoneal dialysate. She was given a dose of
Vancomycin at dialysis empirically to cover for line infection,
after initial cultures were drawn.
.
In the ED, vitals were T:101.1 HR:78 BP:190/101 RR:24 O2Sat:96%
on RA. Repeat blood cultures were drawn and she was given
additional dose of vancomycin and gentamicin. She was
transferred to MICU for management of uncontrolled hypertension.
Past Medical History:
-ESRD on HD: proliferative glomerulonephritis. ? hx of lupus
On steroids several years ago. Diagnosed in [**2122-10-25**] ([**Doctor First Name **]
1:160)
-Bilateral total knee replacement in [**2125-1-23**]
-CAD
-Rheumatic fever
-HTN
-Left shoulder OA
-Left rotator cuff tear
-Hyperparathyroidism
-Iron deficiency anemia
-Hypercholesterolemia
.
PSHx:
Multiple catheter placements for HD, most recently today with
right subclavian catheter.
-Hysterectomy; fibroids
-Bilateral knee replacements [**1-28**]
-Herpes Zoster prior history with resulting post-herpetic
neuralgia right side
Social History:
Lives with housemates in [**Location (un) 669**]. Works as social worker for
DSS, currently not working. One-half pack tobacco per day x32
years- quit 3months ago. Former cocaine user.
Family History:
Father myocardial infarction in his 40s. Uncle with a
myocardial infarction in his 40s. Brother with a myocardial
infarction in his 40s. There is no family history of connective
tissue disease.
Physical Exam:
Tmax: 38.2 ??????C (100.8 ??????F)
Tcurrent: 38.2 ??????C (100.8 ??????F)
HR: 73 (73 - 83) bpm
BP: 159/110(122) {155/92(108) - 174/110(122)} mmHg
RR: 26 (15 - 26) insp/min
SpO2: 99%
Height: 65 Inch
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : ), Tunneled dialysis
catheter without erythema or drainage
Abdominal: Soft, Non-tender, Bowel sounds present, Obese,
Peritoneal dialysis catheter without drainage or inflammation
Extremities: no c/c/e
Skin: Warm
Neurologic: Attentive, Follows simple commands, Oriented (to):
person, place and time
Pertinent Results:
=====ADMISSION LABS=====
[**2128-6-22**] 09:22AM WBC-9.8# RBC-3.65* HGB-11.2* HCT-35.4* MCV-97
MCH-30.8 MCHC-31.7 RDW-14.5
[**2128-6-22**] 09:22AM NEUTS-89 BANDS-0 LYMPHS-5 MONOS-3 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2128-6-22**] 09:22AM GLUCOSE-69* UREA N-39* CREAT-9.4*# SODIUM-136
POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-22 ANION GAP-22*
[**2128-6-22**] 09:50AM PT-24.4* PTT-38.5* INR(PT)-2.4*
[**2128-6-22**] 09:22AM ALT(SGPT)-6 AST(SGOT)-18 LD(LDH)-459* ALK
PHOS-99 TOT BILI-0.4
[**2128-6-22**] 09:22AM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.5#
MAGNESIUM-2.1
[**2128-6-22**] 09:22AM PLT COUNT-329
.
C diff- negative
.
Blood Culture, Routine Drawn [**2128-6-21**] and [**2128-6-22**]: ENTEROBACTER
CLOACAE.
.
All other bloox cx- negative
.
Peritoneal fluid analysisL [**2128-6-25**]
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN. Cx-negative
.
Peritoneal fluid analysis: [**2128-6-26**]
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES, Cx
negative
CXR [**2128-6-22**]
IMPRESSION: Vague nodular density at the left lung base. This
may be due to overlapping structures, although if there is
persistent clinical concern, consider formal PA and lateral
views. Right perihilar atelectasis.
.
U/S UE Veins [**2128-6-22**]
IMPRESSION:
1. Occlusive thrombus within the right internal jugular vein.
Note that
there was right IJ thrombus on Duplex study of [**2127-4-1**].
There have been no interval studies. Therefore, the chronicity
of this thrombus cannot be determined.
.
2. The central extent of the internal jugular thrombus is
indeterminate. Some central occlusion is possible given the
dampened waveforms of the more peripheral veins.
.
Unilateral Breast U/S [**2128-6-22**]
IMPRESSION: Subcutaneous edema, without focal drainable fluid
collection
identified.
If the swelling persists, consider repeat ultrasound and
mammographic
correlation for further evaluation.
.
MRA chest with and without contrast: [**2128-6-29**]
IMPRESSION:
1. Thrombus in the right subclavian and bilateral
brachiocephalic veins and
supra-azygos superior vena cava. The SVC is patent more
inferiorly near its
junction with the right atrium.
2. Chronic thrombosis of the bilateral internal jugular veins
and left
brachiocephalic vein.
3. Patent left subclavian vein which, however, demonstrates
narrowing
proximally.
.
KUB of abdomen for catheter tip placement [**2128-6-30**]:
IMPRESSION: Peritoneal dialysis catheter tip overlying the
pelvic inlet.
Brief Hospital Course:
Pt is a 55 y/o F with hx ESRD, on HD and PD, admitted for
uncontrolled hypertension and gram negative bacteremia.
# Gram negative bacteremia- The patient was found to have GNR
bacteremia which was enterobacter. She was originally started
on gentamicin and ciprofloxacin which was later changed to
ceftazidime when it was found to be pan-sensitive. Her HD
catheter was changed over a wire as there was pus at the
catheter site and she was previously febrile. She needs to be
treated with ceftazidime for a total of 3 weeks with a start
date of [**2128-6-28**] (date of catheter change). The peritoneal fluid
cultures had no growth x2 but the patient was empirically
treated. The PD dialysis fluid on [**6-24**] showed 4+PMNs with a
subsequent sample only having 2+ polys. The pt was started on
vancomycin prior to the PD cx returning as the peritoneal fluid
looked cloudy. Breast ultrasound showed no evidence of abscess
on ultrasound and is less likely to be source of infection given
chronicity. Pt has negative chest imaging and shows no signs of
pulmonary infection clinically. Patient will receive
ceftazidime at hemodialysis treatments.
.
#RIJ Thrombosis/SVC syndrome: The pt has a history of RIJ
thromboses. She was on home Coumadin, which was held initially
and vitamin K was given so she could have her HD line changed
over a wire. While in the hospital the patient was on a heparin
drip. She also had swelling of the R breast at admission. Later
in her hospitalization she developed swelling of the left arm,
neck, face, left breast, and around her eyes. A MRV with and
without contrast was done which showed thrombus in the right
subclavian, bilateral brachiocephalic veins, supra-azygos
superior vena cava, and bilateral internal jugular veins.
[**Month/Day (4) **] surgery was consulted and felt there would be no
benefit from intervention. Patient was discharged with 5mg dose
of coumadin. Her INR will be followed at her [**Hospital **] clinic and
adjusted as necessary.
.
#Breast pain: Breast tenderness is chronic and is likely related
to venous clots. Pt has had no evidence of abscess on
ultrasound, and is unlikely to be the source of infection given
chronicity. Pt was seen by Breast Surgery for further
recommendations, and it was determined that she likely has edema
secondary to a clot in the region of her right subclavian, given
her history of possible trauma to the site 5 months prior during
HD catheter placement. Pt is recommended to have dedicated
breast ultrasound and mammogram as an outpatient as these
studies are not convered by insurance as an inpatient. Also,
patient will follow up with Dr. [**Name (STitle) 17486**] [**Doctor Last Name 11635**] as an
outpatient.
.
#Chest pain: Pt has had several episodes of chest pain,
described as a mix of substernal pressure and heartburn. Repeat
EKGs and cardiac enzymes have been negative. Pain improved
mildly with NG. Also increases with inspiration, which is more
consistent with a pleuritic etiology. Chest pain also improves
after Maalox. Pt was started on a daily PPI.
.
# Hypertension ?????? Per pt, baseline at home is 120/80. She missed
4 days of low-dose atenolol prior to admission. Her BP early in
her admission was elevated in the 170s with a BP max of 200s.
She had another episode of increased BP when she became febrile.
With HD and her home doses of Atenolol and Captopril her blood
pressure was fairly well controlled throughout the rest of her
admission.
.
# ESRD ?????? Pt is on a regular HD schedule of Mon/Fri and also does
regular peritoneal dialysis at home. She received HD 7/30 per
renal as she has been having issues with regular PD, due to
fibrin clotting in her line. She received TPA per her PD tube by
Renal [**6-24**], with improved flow of effluent. The pt is
transitioning from HD to PD due to issues of poor venous access.
In addition her HD catheter had to be changed over a wire
during her admission due to pus at the HD site, blood cx + for
enterobacter, and fevers. While in the hospital she increased
the frequency and volume of her PD dialysis. The ultimate goal
is for her the patient to only need PD so the HD line can be
discontinued. She was continued on her home lanthanum,
sevelamer, Iron, vitamin D, cinacalcet. She will continue with
HD as an outpatient per Dr.[**Name (NI) 17897**] recommendations. Will
also continue PD at home. The goal is to ultimately be on PD
with home nursing.
.
# Psych: The patient has a history of depression on citalopram.
During her hospitalization she had difficulty in adjusting to
the stress of all her medical problems. The patient received
low dose Ativan once a day to help her with her anxiety and was
seen by social work. She denied any suicidal ideation or
intent to harm herself. She needs close follow up with her PCP.
.
#Sleep apnea: While the patient was sleeping her oxyen
saturation was 72% and a pulmonary consult was called. It was
decided the patient should be put on CPAP and continuous oxygen
monitoring. She will get a CPAP machine delivered to her home
and she will follow up with Sleep Health Centers for a sleep
study.
Medications on Admission:
Atenolol 25 mg Tablet [**11-26**] tab Tablet(s) by mouth once a day
Cinacalcet [Sensipar] 60 mg Tablet 1 Tablet(s) by mouth once a
day Citalopram 10 mg Tablet [**11-26**] Tablet(s) by mouth qam
Epoetin Alfa [Epogen] 4,000 unit/mL Solution q hd q hd
Gabapentin 300 mg Capsule 1 Capsule(s) by mouth once a day
Iron Sucrose [Venofer] 100 mg/5 mL Solution 50 mg q wk at HD
Lanthanum [FOSRENOL] 1,000 mg Tablet, Chewable 1 Tablet(s) by
mouth three times a day
Lorazepam 0.5 mg Tablet 1 Tablet(s) by mouth once a day as
needed for stress
Paricalcitol [Zemplar] 5 mcg/mL Solution 6.5 mcg at HD TIW
Sevelamer HCl [Renagel] 800 mg Tablet 3 Tablet(s) by mouth three
times a day Warfarin [Coumadin] 5 mg Tablet 1 Tablet(s) by
mouth once a day
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for anxiety.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. Paricalcitol
Paricalcitol 6.5 mcg IV QHD
11. Ferric gluconate
Ferric Gluconate 125 mg IV QWEEK AT HD
12. ceftazidime
CeftazIDIME 1 g IV 3X/WEEK (MO,WE,FR) Duration: 3 Weeks with
start date [**2128-6-28**]
13. Outpatient Lab Work
Please check INR at next HD session
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
16. Ferric Gluconate 125 mg IV QWEEK AT HD
17. CPAP
CPAP with 2L O2
Auto CPAP range 4-20
Diagnosis: OSA
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] of [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
1. Septic infection (due to HD line)
2. SVC
3. Venous clots
4. ESRD on HD and PD
5. Depression
6. HTN
.
Secondary Diagnosis
1. CAD
2. Left rotator cuff tear
3. Hyperparathyroidism
4. Left shoulder OA
5. Hypercholesterolemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital due to a bacterial infection
due to your HD catheter which has pus at its site. You were
also admitted with hypertension because you had recently missed
doses of your medication. While you were at the hospital you
were found to have enterobacter bacteria in your blood stream.
You were treated with antibiotics. Your HD catheter was changed
over a wire. You also developed a clot in your right internal
jugular vein early on in your hospitalization and were treated
with a heparin drip. You also developed clots in:
1. the right subclavian vein
2. bilateral brachiocephalic veins
3. supra-azygos superior vena cava
4. bilateral internal jugular veins
.
The clots lead to swelling of your head, neck, and around your
eyes. You were transitioned from heparin to coumadin prior to
discharge to prevent further development of clots.
.
Please follow up with your regular hemodialysis doctor, Dr.
[**First Name (STitle) 805**], for your renal disease management, dosing of your
antibiotics, and management of your coumadin by checking your
INR blood test.
.
Also, you were started on CPAP machine at night for your
suspected sleep apnea. You will be getting a CPAP machine
delivered to your home in the next few days. You will have to
get a formal sleep study at Sleep Health Centers located in
[**Location (un) 583**]. You will have to give the prescription for the CPAP
and the information of the sleep center to the CPAP delivery
company.
.
If you develop shortness of breath, chest pain, further swelling
of your face/neck/upper extremities, redness or pus of your
catheter site, fevers, suicidal ideation, or any other worrisome
symptonm please seek medical attention.
Followup Instructions:
Please follow up with your primary care [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) 507**]
[**Doctor First Name 508**] [**Telephone/Fax (1) 133**] in the next week. Please address difficulty
coping with your medical problems at this visit.
.
Please have INR checked and antibiotic dosing at next HD with
Dr. [**First Name (STitle) 805**]
.
Please follow up in the renal clinic in one week.
.
Please obtain outpatient mammogram and outpatient ultrasound
which will be set up by your PCP.
.
Please make an appointment to see Dr. [**Name (STitle) 17486**] [**Doctor Last Name 11635**]
regarding your breast swelling. Her clinic phone number is
[**Telephone/Fax (1) 17898**]
.
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2128-10-4**] 1:00
.
Sleep study to be scheduled at Sleep Health Centers, [**Location (un) 17899**] [**Location (un) 583**], [**Numeric Identifier 994**] ([**Telephone/Fax (1) 17900**]
Completed by:[**2128-7-6**]
ICD9 Codes: 5856, 2720 | [
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train_15137 | completed | a6def893-ce08-4246-90ed-0c6480beb1eb | Medical Text: Admission Date: [**2147-3-7**] Discharge Date: [**2147-3-7**]
Date of Birth: [**2063-3-10**] Sex: M
Service: MEDICINE
Allergies:
Amlodipine
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Expired
History of Present Illness:
(per OMR and the patient's family as he is unable to give
history due to AMS): 83 yo male with DM, COPD, h/o MSSA PNA, CHF
(multiple recent hospitalizations for decompensated CHF), AVR
with restenosis (valve area 1.2 in [**Month (only) **]), recent admission
for new Afib and symptomatic NSVT (no intervention but BB
uptitrated), found to have worsening O2 status at his rehab.
Patient's daughter went to visit him at reham yesterday and his
02 was 'in the low 80s' on oxygen and he was coughing
(non-productive). They decided to try to increase his 02 and
wait overnight to see if there was improvement, was given
morphine sulfate x3 but had no improvement so family brought him
to [**Hospital1 18**]. Patient's family notes that he seems more aggitated
and uncomfortable today but otherwise similar mental status with
poor short term memory, waxing/[**Doctor Last Name 688**] mental status.
.
On review of OMR notes, he has had multiple hospitalizations
over last few months for CHF and pneumonia. He was admitted in
[**9-21**] with L/R sided HF, readmitted in [**11-21**] with weight gain,
SOB, found to be in acute heart failure complicated by new onset
afib at which point he was started on coumadin. TTE at that time
showed EF 45-55%, aortic valve area 1.2, severe [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], 3+
tricuspid regurg, 2+ pulmonic
regurg. mild diffuse hypokinesis and mild depression of
contractility of L/R ventricle. Admitted again [**2146-12-31**] and
intubated for acute respiratory decompensation [**2-14**] CHF, also
treated for MSSA pneumonia. Admitted [**1-27**] for NSVT and new Afib,
treated with increasing dose of BB. Patient has also recently
worked up for altered mental status thought most likely [**2-14**]
toxic metabolic.
.
In the ED, initial vs were: 97.9 60 118/45 17 98 on. Labs
notable for a WBC count of 13.9, HCT 34.4, Cr. 1.7 and troponin
0.10. BNP pending. Lactate 1.0., INr 3.3. abg: Ph7.27 pCO2 76
pO2 78 HCO3 36. CXR with large right pleural effusion. Patient
was given Vanco 1g IV, Levofloxacin 750mg, Ceftriaxone, and
Methyprednisone 125. He was then given aspirin 600 PR. Cards
was consulted who said it is likely demand due to a large
pleural effusion with someone with known coronary artery
disease. They did not look at the EKGs. EKG showed v1 and v2 ST
depressions, 1-2 mm. Vitals currently: 61 120/41 98% on Bipap
[**5-17**] 40%. DNR/DNI confirmed with patient and his family in the
ED.
.
On the floor, the patient is wearing bipap and appears to be
working hard to breath. He reports feeling like he can't
breathe. His family (3 daughters, one of whom is his HCP)
report that he appears uncomfortable and again report that the
patient wants to be DNR/DNI.
.
Dr. [**Last Name (STitle) 665**], his PCP came in and a family meeting was held with
Dr. [**Last Name (STitle) **], the MICU resident and the patient's 3 daughters.
The family was updated on the patient's situation and his low
likelihood of recovery without intubation (and very low
likelihood of cure regardless). All three sisters were in
agreement that the patient was clear that he did not want to be
intubated, they felt that intubation and CPR would cause him
more suffering and felt comfortable with keeping the patient
DNR/DNI. Plan was to try lasix, antibiotics and Bipap to see if
it was possible to improve the patient's respiratory status but
to also make the patient comfortable with morphine even if this
decreased his respirations. The sisters requested a catholic
priest for the patient as well as some time to update their
other 5 siblings.
.
Review of systems(per family):
(+) Per HPI
(-) Denies fever, recent weight loss or gain. Denies sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies nausea, vomiting, diarrhea, Denies
rashes or skin changes.
Past Medical History:
1. Multiple admissions since [**Month (only) **] with respiratory
decompensation, pneumonia, congestive heart failure.
Previously admitted to [**Hospital 38**] [**Hospital **] Hospital on
[**2146-12-31**] then [**2147-1-21**].
2. Diabetes mellitus, insulin dependent.
3. Chronic renal disease, stage III.
4. Cardiomyopathy and congestive heart failure.
5. History of CABG times 2.
6. Aortic valve replacement [**2140**].
7. Chronic venous stasis with cellulitis.
8. Hyperlipidemia.
9. Hypertension.
10. Morbid obesity.
11. Depression.
12. GERD.
13. Diabetic polyneuropathy.
14. Afib
15. NSVT
Social History:
The patient lives alone. Has some elderly services but dependent
on daughter who visits every day. They note that he is not
always compliant with his medications. Widowed. Has eight
children who are very supportive. Goes to senior center every
day. Quit smoking > 30 years ago. Rare EtOH. Used to work in
commercial insulation.
Family History:
Mother had heart disease.
Physical Exam:
Tmax: 36.1 ??????C (97 ??????F)
Tcurrent: 36.1 ??????C (97 ??????F)
HR: 60 (60 - 66) bpm
BP: 119/42(61) {94/34(55) - 120/56(61)} mmHg
RR: 20 (17 - 24) insp/min
SpO2: 94%
Heart rhythm: AF (Atrial Fibrillation
General Appearance: Overweight / Obese, increased WOB
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: with BIPAP on
Cardiovascular: lound mechanical click, no audible murmur
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Crackles : on left, Wheezes
: mild expiratory on left, Diminished: right side 2/3 up
anteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, dusky venous stasis changes bilaterally, no
warmth
Skin: Not assessed, No(t) Rash:
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Admission labs:
[**2147-3-7**] 10:50AM BLOOD WBC-13.9* RBC-3.78* Hgb-10.2* Hct-34.4*
MCV-91 MCH-26.9* MCHC-29.6* RDW-17.8* Plt Ct-213
[**2147-3-7**] 10:50AM BLOOD Neuts-85.6* Lymphs-10.0* Monos-3.7
Eos-0.6 Baso-0.1
[**2147-3-7**] 10:50AM BLOOD PT-33.1* PTT-38.1* INR(PT)-3.3*
[**2147-3-7**] 10:50AM BLOOD Glucose-75 UreaN-53* Creat-1.7* Na-145
K-5.1 Cl-104 HCO3-38* AnGap-8
[**2147-3-7**] 10:50AM BLOOD CK(CPK)-20*
[**2147-3-7**] 10:50AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 22275**]*
[**2147-3-7**] 10:50AM BLOOD cTropnT-0.10*
[**2147-3-7**] 10:50AM BLOOD Calcium-9.7 Phos-4.8*# Mg-2.4
[**2147-3-7**] 11:46AM BLOOD Type-ART pO2-78* pCO2-76* pH-7.27*
calTCO2-36* Base XS-4 Intubat-NOT INTUBA
[**2147-3-7**] 10:54AM BLOOD Lactate-1.0
Brief Hospital Course:
As per HPI, a family meeting was held with the patient's family,
the MICU attending, and the patient's primary care physician,
[**Name10 (NameIs) 4120**] goals of care. He DNR/DNI status was affirmed.
[**Hospital **] medical strategies such as diuresis, antibiotics,
and positive pressure ventilation masks were pursued. The
patient, however, did not tolerate the BiPAP mask and was
clearly uncomfortable, despite morphine boluses. Further
discussions were held with the family, and the patient was
transitioned to comfort measures only status. He was placed on a
morphine drip with PRN ativan available. He passed away
peacefully with his family at his side, shortly thereafter.
Medications on Admission:
Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
Lantus 100 unit/mL Cartridge Sig: Thirty (30) units
Subcutaneous in the mornings.
Insulin Regular Human 100 unit/mL Cartridge Sig: dose
depends on glucose finger stick Injection daily.
Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day.
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
ICD9 Codes: 486, 5119, 4254, 4280, 4241, 3572 | [
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train_15340 | completed | 8acc4810-e9ea-4a7f-b252-02453fa43baf | Medical Text: Admission Date: [**2134-4-16**] Discharge Date: [**2134-4-19**]
Date of Birth: [**2068-9-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This 65-year-old woman with a
history of chronic thoracoabdominal aneurysm diagnosed three
years ago, who declined surgery at that time, was admitted
with abdominal pain. She was admitted to the Medicine
service and rapidly referred to Vascular Surgery.
PAST MEDICAL HISTORY:
1. Thoracoabdominal aneurysm.
2. Hypertension.
3. Obesity.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide.
2. Labetalol.
ALLERGIES: Patient had no known allergies.
HOSPITAL COURSE: The patient was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
Vascular Surgery who agreed that she was symptomatic with an
extensive thoracoabdominal aneurysm with dissection and a
very grave prognosis. He had a family discussion and the
patient was then referred on also to CT Surgery and was seen
by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] and Dr. [**First Name (STitle) 18078**] ....................
Given her chronic history and her new symptoms, it was deemed
that she should be taken to the Operating Room. Preoperative
information as follows:
Laboratories were as follows: White count of 6.0, hematocrit
of 27.6, platelet count 169,000. The patient had an INR of
1.2. K was 3.8, BUN 11, creatinine 1.0, and a blood sugar of
119.
The CT scan demonstrated a false lumen. Please refer to the
radiology report.
Re[**Last Name (STitle) **]dations were to keep blood pressure under control and
the patient was then seen by Vascular, again, and Dr. [**Last Name (Prefixes) 411**]. She remained in the Coronary Care Unit on labetalol
and IV Nipride for blood pressure management in preparation
for possible operation. She went to the cardiac
catheterization lab which demonstrated normal coronaries and
the previously noted aortic disease. She was also
transfused, prior to coming to the Operating Room, to raise
her hematocrit. Her BUN rose to 1.5 post catheterization.
A TTE showed normal LV and RV function. She had 2+ AI and
aortic root that was dilated to greater than 4 cm.
The patient was brought to the Operating Room. Please refer
to the operative note dictated by both Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient underwent a
thoracoabdominal aneurysm repair with partial bypass. The
patient did not survive the operation and expired in the
Operating Room on [**2134-4-19**]. Please refer to the operative
note.
For coding purposes, discharge diagnoses as follows:
1. Status post thoracoabdominal aneurysm repair.
2. Chronic aneurysm with acute dissection.
3. Hypertension.
4. Obesity.
Again, the patient expired in the Operating Room on [**2134-4-19**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 37991**]
MEDQUIST36
D: [**2134-10-13**] 14:56
T: [**2134-10-19**] 07:25
JOB#: [**Job Number 40670**]
ICD9 Codes: 2851, 2762, 4019, 2767 | [
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train_15348 | completed | 30624de2-4938-4a59-afd5-f0b2fadc6d3a | Medical Text: Admission Date: [**2188-9-14**] Discharge Date: [**2188-9-18**]
Date of Birth: [**2143-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
TLC placement in Left IJ
History of Present Illness:
HPI: 46yoM w/ h/o polysubstance abuse, st. jude's valve
placement for endocarditis (approx. 10 yrs ago) presented to the
ED after having been found wandering the streets acting "odd"
and agitated per EMS ("shaking movements" per bystanders prior
to EMS arrival). He reported feeling "unwell" over the past 3
days with diffuse joint/muscle aches, subjective fever, no
appetite, nausea/vomiting/diarrhea; diarrhea, he said was a
chronic problem for him. He reports that he had a fight with his
wife nearly a week ago and has been using heroin (injecting),
cocaine (smoking), and EtOH since then. He had not used these
several months prior to that. He denied CP and SOB.
Upon arrival to the ED, he was found to be agitated and
tachycardic. Initial vitals revealed T 96.6 HR 133 BP 113/79 RR
20 O2sat 93% RA. An EKG demonstrated sinus tach at a rate of 106
and was w/o significant STTW changes. Urine tox was positive for
cocaine and opiates. He received 2L IVFs for ARF and SBPs in the
90s. Given his significant bandemia, blood cultures were drawn.
A CXR was obtained which did not reveal evidence of an
infiltrate. UA did show hematuria, but only showed rare bacteria
and 1 WBC. Lactate, however, was found to be elevated to 3.9.
Given his hypotension, bandemia, and ARF in the setting of IVDA,
the patient was transferred to the ICU for sepsis evaluation and
possible endocarditis eval.
Past Medical History:
Polysubstance abuse (cocaine, heroin, EtOH); currently
undergoing treatment w/ suboxone at [**Location 8391**] Mental Health
Center
Endocarditis s/p st. jude's valve [**11-21**] yrs ago at [**Hospital1 2025**]
Hep C and B
Anxiety
Depression
Rotator cuff tear
Social History:
Lives at home with wife and her two children. Not currently
working. Prior to past week, had been sober x "several months."
Over past week has been smoking cocaine, shooting heroin,
drinking EtOH.
Family History:
non-contributory
Physical Exam:
PE: T 100.9 BP 110/59 HR 105 RR 20 O2 sat 97% on 2L NC
Gen: Appears agitated and uncomfortable, asks for water
Skin: Ecchymoses left deltoid
HEENT: PERRL, very dry MM, upper dentures in place, poor
dentition but no evidence of abscess, purulent drainage
Neck: Supple
CV: Sinus tachycardia, 3/6 systolic murmur heard throughout
precordium > R and L upper sternal borders.
Resp: Decreased BS right lung bas to mid lung field, rare exp.
wheeze right upper lung field o/w CTAB
Abd: +BS, soft, ND, TTP over epigastrium, no rebound/guarding
Ext: Left 4th and 5th toes with ecchymoses and swelling, unable
to flex extend toes w/o significant pain, no bony
abnormalities/step offs. No splinter hemorrhages, no osler nodes
Neuro: CN 2-12, strength, sensation grossly intact
Pertinent Results:
[**2188-9-14**] 05:36PM URINE RBC-6* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2188-9-14**] 05:36PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2188-9-14**] 12:57PM LACTATE-2.0
[**2188-9-14**] 05:16AM GLUCOSE-96 UREA N-14 CREAT-1.3*# SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14
[**2188-9-14**] 05:16AM ALT(SGPT)-164* AST(SGOT)-211* LD(LDH)-446*
ALK PHOS-51 AMYLASE-40 TOT BILI-1.1
[**2188-9-14**] 05:16AM LIPASE-15
[**2188-9-14**] 05:16AM ALBUMIN-2.9* CALCIUM-6.8* PHOSPHATE-3.1
MAGNESIUM-1.3*
[**2188-9-14**] 05:16AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-POSITIVE
[**2188-9-14**] 05:16AM HCV Ab-POSITIVE
[**2188-9-14**] 05:16AM WBC-13.9* RBC-3.96* HGB-13.4*# HCT-37.8*
MCV-96 MCH-33.8* MCHC-35.4* RDW-12.8
[**2188-9-14**] 05:16AM NEUTS-90* BANDS-4 LYMPHS-1* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2188-9-14**] 05:16AM PT-30.4* PTT-58.3* INR(PT)-3.2*
[**2188-9-13**] 09:35PM GLUCOSE-104 UREA N-16 CREAT-2.5* SODIUM-142
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-19
[**2188-9-13**] 09:35PM NEUTS-85* BANDS-13* LYMPHS-1* MONOS-0 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
Brief Hospital Course:
1. Hypotension: Patient's baseline BP was initially unknown. He
was given aggressive IV hydration and placed on broad spectrum
antibiotics with vanc/zosyn/flagyl for presumed sepsis and
monitored in the ICU. He was pan cultured prior to starting
antibiotics and central access was obtained via a right IJ for
adequate fluid resuscitation. The patient defervesced and did
not require pressors during his stay. A TEE was obtained given
our concern for endocarditis in the setting of IVDA, hypotension
and presumed bacterial sepsis. This showed no signs of
vegetations with a well seated valve. Given his negative
culture form blood and urine, his normalization of the wbc count
and his afebrile state, the antibiotics were discontinued and he
remained stable through the course of the hospitalization.
2. ARF: Pt had an elevated serum creatinine on admission and
appeared markedly volume depleted. Urine lytes were obtained and
consistent with a pre-renal state. The serum creatinine trended
back to normal limits with IV hydration.
3. Elevated transaminases and t.bili: Per pt. report has h/o hep
B/C. His AST/ALT were mildly elevated on admission with a
normal bilirubin and alk phos suggestive of non-obstructive
process. He ws instructed to follow up with his PCP for repeat
LFTs.
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Neurontin 800 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*2*
3. Klonopin 1 mg Tablet Sig: One (1) Tablet PO four times a day
as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
hypotension
[**Hospital3 9642**] valve
IVDA
sepsis
ARF
Discharge Condition:
good
Discharge Instructions:
Patient should return to the ER if he develops fevers, chills,
lightheadedness, chest pain or SOB.
Followup Instructions:
Patient will need to follow up with his PCP Dr [**Last Name (STitle) 73486**] at
[**Telephone/Fax (1) 6511**] in 1 week. He should have his INR checked tomorrow
to see if the coumadin dose needs to be adjusted over the
weekend. He is being discharged on a lower dose of coumadin
than previously taking.
ICD9 Codes: 0389, 5849 | [
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train_14428 | completed | ef597a4f-8ab6-47fe-91e2-bebd7499b286 | Medical Text: Admission Date: [**2170-11-20**] Discharge Date: [**2170-11-22**]
Date of Birth: [**2170-11-20**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 26079**] is the 3.399 gm
product of a 37 week gestation born to a 36 year old gravida
2, para 1 mother. Prenatal screens - AB positive, antibody
negative, hepatitis surface antigen negative, RPR
nonreactive. Rubella immune, GBS unknown. Maternal history,
IVDES exposure, prior obstetric history of delivery of 38
weeker, female by cesarean section in [**2170-12-8**]. This
pregnancy essentially uncomplicated. Mother carrier for
fragile X, early CVS of this pregnancy revealed normal
chromosomes, no fragile X, mother on several courses of
antibiotics for sinus infections. Also experienced lower
abdominal pains which turned out to be a hernia repaired
during the cesarean section. Delivery by repeat cesarean
section done one week early due to increase in blood
pressures. No sepsis risk factors.
PHYSICAL EXAMINATION: Infant with Apgars of 8 and 8 with
persistent grunting requiring admission to the Neonatal
Intensive Care Unit for respiratory distress. Examination
revealed birthweight 3390 gm, 90th percentile, head
circumference 34.75 cm, 98th percentile, length 48.5 cm, 50th
to 75th percentile. Anterior fontanelle soft and flat. Eyes
deferred. Palate intact. Lungs clear and equal. He had
grunting and tachypneic, regular rate and rhythm, no murmur.
2+ femoral pulses. Abdomen soft, positive bowel sounds.
Genitourinary, normal male, testes down bilaterally.
Meconium in diaper. Extremities, pink and well perfused.
HOSPITAL COURSE: Respiratory - [**Known lastname 3979**] was placed on nasal
prong CPAP with 6 cm of water requiring maximum of 30% oxygen
for the first 24 hours of life. He then transitioned to room
air and has been stable in room air since that time.
Cardiovascular: No issues.
Fluids, electrolytes and nutrition - Initially started on 60
cc/kg/day of D10/W. Infant initiated enteral feedings on day
of life #1 and is currently adlib feedings without issue.
His discharge weight was 3.295 kg.
Gastrointestinal/bilirubin - His bilirubin on day of life #1
was 5.2/0.2 and did not require any intervention.
Hematology - Hematocrit on admission was 48.
Infectious disease - Complete blood count and blood culture
were obtained on admission. Complete blood count was benign.
Blood culture remained negative. Antibiotic was continued at
48 hours.
Sensory - Audiology has not been performed and will be done
in Newborn Nursery
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To Newborn Nursery.
PRIMARY CARE PEDIATRICIAN: Dr. [**First Name (STitle) 50952**] [**Name (STitle) **] at [**Location (un) 246**]
[**State 350**]. Telephone [**Telephone/Fax (1) 37501**].
MEDICATIONS ON DISCHARGE: Not applicable.
CARSEAT POSITION SCREENING: Not applicable.
STATE NEWBORN SCREENS: Sent.
IMMUNIZATIONS: Hepatitis B vaccine was given on [**2170-11-22**].
DISCHARGE DIAGNOSIS:
1. Transitional respiratory distress
2. Status post rule out sepsis with antibiotics.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 38294**]
MEDQUIST36
D: [**2170-11-22**] 19:21
T: [**2170-11-22**] 19:52
JOB#: [**Job Number 50953**]
ICD9 Codes: V290, V053 | [
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train_14496 | completed | 33dd9cd6-c869-4f98-adb3-03c642a14e93 | Medical Text: Admission Date: [**2157-2-12**] Discharge Date: [**2157-3-11**]
Date of Birth: [**2118-9-29**] Sex: F
Service:
woman with a history of crack-cocaine abuse. On [**2-12**] she was
found at home responsive. She had vomited and aspirated.
She was brought to [**Hospital 47**] Hospital, where a head CT
subarachnoid bleed and left anterior communicating artery
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2157-2-12**]. She went to the
communicating aneurysm.
Please see other dictation summary
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
D: [**2157-3-14**] 11:59
T: [**2157-3-14**] 12:03
JOB#: [**Job Number **]
ICD9 Codes: 5185, 5070, 2930, 4019, 2859 | [
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train_14602 | completed | 3488291e-1bb7-4bba-8347-84b873493503 | Medical Text: Unit No: [**Numeric Identifier 73571**]
Admission Date: [**2157-7-7**]
Discharge Date: [**2157-8-19**]
Date of Birth: [**2157-7-7**]
Sex: F
Service: NB
HISTORY: This is a 30-week twin girl #2 admitted for
prematurity. The infant was born to a 38-year-old G1 P0
mother whose [**Name2 (NI) **] type is 0-negative, RPR non-reactive,
rubella immune and hepatitis B surface antigen negative. Her
pregnancy was significant for di-di twins which were
conceived via IVF and complete previa. Mom did receive
RhoGAM at 28 weeks. Mom presented with vaginal bleeding on
[**2157-7-4**], and required a red [**Year (4 digits) **] cell transfusion. Secondary
to persistent bleeding, they decided to deliver
the twins. She did receive betamethasone with the first dose
on [**2157-7-4**], and she was beta-complete. No pre-term
contractions and no rupture of membrane. Infant was born via
C-section, Apgars of 7 and 8. She emerged with fair
respiratory effort and central cyanosis. She received C-Pap
with improvement in color. Oxygen saturations were normal by
5 minutes of age. She was transferred to the NICU.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98, heart
rate 170, BP 75/38 (51), oxygen saturation is 91% on C-Pap
room air. Weight 14.15 gm (50-75%), head circumference 28 cm
(50%), length 39 cm (25-50%). Baby is [**Name2 (NI) **] with poor
aeration bilaterally prior to C-Pap. Her anterior fontanel
is open and flat. Palate intact. Normal S1, S2, no murmur,
breath sounds present. Abdomen soft, nontender,
nondistended. Extremities are well-perfused. Legs in breech
position. Patient supine. Hips stable. Skin is patent, no
rash. Prominent labium majora with probable mucosal cyst.
PHYSICAL MEASUREMENTS AT DISCHARGE:
Weight: 2640g, Head circumference 32 cm, Length 46 cm.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Upon admission baby was started on [**Name (NI) **] of
6 and was quickly intubated and received one dose of
surfactant. She was weaned to nasal C-Pap on day of
life 1 and was weaned to room air on day of life 4. She
was continued on room air since that time. She did have
apnea of prematurity that was treated with caffeine
which was stopped on day of life 29 and she has been
greater than 5 days without a spell.
2. Cardiovascular: Upon admission she had a normal [**Name (NI) **]
pressure and heart rate. She never required pressors or
boluses. She was found to have a soft murmur for which
she got an echocardiogram on [**2157-7-13**] (day of life 6),
which demonstrated a small less than 1 mm PDA with
continuous left-to-right flow, otherwise a normal
examination. She has no murmur currently and she
continues to have a stable cardiac examination.
3. Fluids, electrolytes, nutrition: Baby was started NPO.
She had a UVC placed and did received PN through day of
life 9. She started feeds on day of life 3 which were
advanced as tolerated. She currently is on ad lib p.o.
feeds of breast milk 24 or Enfamil 24 kcals, which she
tolerates well.
4. GI: Baby was found to have hyperbilirubinemia and
received 3 days of phototherapy with a peak bilirubin of
7.2/0.3 on day of life 9. No current issues.
5. Hematology: At birth a CBC showed a hematocrit of 49.7
and platelets of 327. Her most recent CBC was on
[**2157-7-23**], or day of life 26, which showed a hematocrit
of 32.3 and platelets of 606 and a reticulocyte count of 3.
She was on iron and vitamin E. The vitamin E was
discontinued and she continues on iron and multivitamin.
6. Infectious disease: A rule out sepsis workup was done at
birth with a white count of 7.9 with 38 polys, 0 bands,
2 metamyelos and 1 myelocyte. A [**Year (4 digits) **] culture was done
that was negative. She was treated with ampicillin
and gentamycin for 48 hours. She has had no further
infectious issues.
7. Neurology: Baby had a normal neurologic examination at
birth and had 2 head ultrasounds which were both normal,
the most recent being on [**2157-8-9**].
8. Sensory:
a. Audiology hearing screening was performed with
automated auditory brain stem responses which baby
passed on [**2157-8-18**].
b. Ophthalmology: Eyes examined most recently on
[**2157-8-17**], revealing immaturity of the retinal vessels
but no ROP as of yet. A followup examination should be
scheduled in 3 weeks from discharge.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73572**], M.D. in [**Hospital1 2436**]
phone# ([**Telephone/Fax (1) 56989**]
CARE RECOMMENDATIONS:
1. Feeds at discharge: Please continue breast milk or
Enfamil 24 kcals.
2. Medications: Iron sulfate 2 mg/kg per dose daily and
multivitamin one mL p.o. daily.
3. Iron and vitamin D supplementation.
a. Iron supplementation is recommended for preterm
and low birth weight infants until 12 months corrected
age.
b. All infants fed predominately breast milk should
receive vitamin D supplementation at 200 IU (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening was done on [**2157-8-18**],
which was passed.
5. Newborn screening: The baby had several newborn screens,
the most recent on [**2157-8-17**], of which the results are
pending. All of the other newborn screens were normal.
6. Immunizations received: Hepatitis B immunization was
given on [**2157-8-6**].
7. Immunizations recommended:
a. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 4 criterion: (1) Born at less than 32 weeks;
(2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities,
or school-age siblings; (3) chronic lung disease; (4)
hemodynamically significant congenital heart disease.
b. Influenza immunization is recommended annually in
the fall for all infants once they reach 6 months of
age. Before this age (and for the first 24 months of
the child's life), immunization against influenza is
recommended for household contact and out-of-home
caregivers.
c. This infant has not received rotavirus vaccine.
The American Academy of Pediatrics recommends initial
vaccination of pre-term infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks or fewer than 12 weeks of
age.
8. Followup appointments scheduled/recommended: (1) A
pediatrician's appointment is scheduled for Tuesday,
[**2157-8-23**], (2) Ophthalmology followup needs to be
scheduled for the 3rd week in [**Month (only) **].
DISCHARGE DIAGNOSES:
1. Prematurity at 30-0/7 weeks' gestation.
2. Respiratory distress syndrome.
3. Rule out sepsis.
4. Twin gestation.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2157-8-18**] 13:05:42
T: [**2157-8-18**] 14:05:30
Job#: [**Job Number 73573**]
ICD9 Codes: 769, 7742, V053, V290 | [
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train_12191 | completed | bada8a5a-90a4-4850-80de-c909801a7339 | Medical Text: Admission Date: [**2187-3-30**] Discharge Date: [**2187-4-6**]
Date of Birth: [**2131-3-30**] Sex: M
Service: MEDICINE
Allergies:
Benadryl Allergy / AmBisome / Flomax / Tacrolimus
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 56 year old male with a history of AML s/p double cord
bone marrow transplant over three years ago, COP who presents
with one day of sore throat, nose pain/sinus pain, headache, and
fever to 103.2 this morning. He also endorses 2 episodes of
vomiting (without nausea), cough, chills, and rigors. He was in
his usual state of health until last evening when he started to
feel unwell, and started experiencing malaise, and headache.
This morning things worsened to the point where he was unable to
get himself into the car because of fatigue/weakness. He has
history of apnea requiring intubation 3 years ago. Also, patient
is on 2L home O2 (use with a lot of activity but not at rest)
for COP.
.
He has not ahd any recent history of travel, hiking, or sick
contacts. His wife states they had a vacation planned, but
haven't done anything recently because he has been unwell. He
has chronic arthralgias from GVHD, but they have been well
controlled and they have been able to wean his prednisone down
to 3mg. He also has had a decrease in his pain requirement and
is now only on oxycontin.
.
Of note prior admission in [**Month (only) **] with fever, malaise,
vomiting. He was afebrile during his admission. He was started
on cipro for possible GI source and his voriconazole (for
aspergillus sinusitis) was discontinued given interaction with
Cipro.
.
In the ED, initial VS were: 100.2 120 109/56 20 94%. CXR with
?LLL infiltrate. Looked dry, IVC collapsible on beside U/S.
Started on IVF and ceftx, azithromycin. SBP down to 79, given
hydrocort 25mg. With persistent hypotension, broadened with
vancomycin and ceftazidime, as well as another hydrocort 75mg.
Awaiting oseltamivir. Now on 3rd and 4th L IVF. Pt notes wanting
to avoid CVL. Rapid flu negative, nasal swab pending. Labs
notable for WBC 11.8, CKD (at baseline), elevated BNP. Currently
alert and appropriate, maintaining airway, breathing
comfortably. Access is 18g and 20g PIV. Current VS: 90 94/44 12
100,4L.
.
On the floor, He is lethargic, but appropriate. He wakes to
voice, and follows commands appropriately. Answering questions,
oriented.
Past Medical History:
-AML M5B
-- S/p idarubicin, Ara-C, mitoxantrone, etoposide and
cytarabine
-- S/p double cord transplant in [**2184**]
-- Prior GVHD, specifically myalgias, arthralgias, Fe overload,
peripheral neuropathy
-Chemotherapy-associated cardiomyopathy, LVEF 50%
-CKD
-DM due to prednisone
-Hemochromatosis with chronic liver disease
-Aspergillus of the sinuses and nares
-Sarcoid diagnosed in [**2172**] on intermittent steroids
-Hypertension
-GERD
-Hypercholesterolemia
-BOOP in [**2184-3-13**] on occasional home oxygen
Social History:
Formerly worked as auto mechanic, now disabled secondary to AML
and GVHD. Lives with wife and son. Past tobacco use, but non
currently.
- Tobacco: Prior to AML diagnosis, he was a smoker, but quit 5
years
- Alcohol: only very occassionally
- Illicits: None
Family History:
Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.
Physical Exam:
ON ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, unable to see
posterior pharynx
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles bilaterally at the bases to the mid lungs
otherwise clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Somewhat distant heart sounds, Regular rate and rhythm,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis,
trace edema
Neuro: PERRL, EOMI, strength 5/5
.
ON DISCHARGE:
Stable from admission exam with exception of clear lung exam,
and improved hypotension.
Pertinent Results:
ADMISSION LABS:
[**2187-3-30**] 11:30AM BLOOD WBC-11.8* RBC-3.59* Hgb-11.9* Hct-36.1*
MCV-101* MCH-33.1* MCHC-32.9 RDW-13.6 Plt Ct-131*
[**2187-3-30**] 11:30AM BLOOD Neuts-86* Bands-0 Lymphs-4* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2187-3-30**] 11:30AM BLOOD PT-14.6* PTT-28.4 INR(PT)-1.3*
[**2187-3-30**] 11:30AM BLOOD Glucose-110* UreaN-43* Creat-2.1* Na-141
K-5.3* Cl-107 HCO3-22 AnGap-17
[**2187-3-30**] 11:30AM BLOOD ALT-23 AST-18 LD(LDH)-145 AlkPhos-199*
TotBili-0.3
[**2187-3-30**] 11:30AM BLOOD proBNP-2580*
[**2187-3-30**] 11:30AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.0*# Mg-1.7
[**2187-3-30**] 12:14PM BLOOD Lactate-2.1*
[**2187-3-30**] 02:10PM BLOOD Lactate-1.2
.
DISCHARGE LABS
[**2187-4-6**] 07:40AM BLOOD WBC-6.6 RBC-3.23* Hgb-10.5* Hct-33.4*
MCV-103* MCH-32.4* MCHC-31.4 RDW-13.3 Plt Ct-142*
[**2187-4-6**] 07:40AM BLOOD Neuts-77.0* Lymphs-7.5* Monos-8.0
Eos-7.3* Baso-0.3
[**2187-4-6**] 07:40AM BLOOD PT-13.8* PTT-28.7 INR(PT)-1.2*
[**2187-4-6**] 07:40AM BLOOD Glucose-89 UreaN-14 Creat-1.2 Na-143
K-4.3 Cl-110* HCO3-23 AnGap-14
[**2187-4-6**] 07:40AM BLOOD ALT-49* AST-22 LD(LDH)-131 AlkPhos-140*
TotBili-0.2
[**2187-4-6**] 07:40AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6
.
MICRO:
Blood culture [**3-30**]: NEG
Urine culture [**3-30**]: NEG
Respiratory viral screen: NEG
CMV viral load: non-detecable
Stool culture [**4-2**]: NEG
C Diff: NEG x2
Legionella urinary antigen: NEG
Aspergilus galactomannan: 0.1 (ref <0.5)
C Diff PCR: PENDING ON DISCHARGE
.
URINE:
[**2187-3-30**] 02:45PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2187-3-30**] 02:45PM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
[**2187-3-30**] 02:45PM URINE CastHy-3*
[**2187-3-30**] 02:45PM URINE AmorphX-FEW
[**2187-3-30**] 02:45PM URINE Mucous-RARE
[**2187-3-30**] 02:45PM URINE Hours-RANDOM UreaN-608 Na-39 K-73 Cl-47
[**2187-3-30**] 02:45PM URINE Osmolal-453
.
CXR [**2187-3-30**]:
The cardiac, mediastinal and hilar contours are normal. The
pulmonary vascularity is not engorged. Patchy opacity is noted
within the left lung base. The right lung is grossly clear. No
pleural effusion or pneumothorax is present. There are mild
degenerative changes in the thoracic spine. Right-sided rib
excrescences are again demonstrated.
IMPRESSION:
Patchy opacity in left lung base which may be infectious in
etiology.
Brief Hospital Course:
56 year old male with a h/o AML, CKD, and possible COP, now s/p
double cord transplant over three years ago who presents with a
1 day history of fever, cough, malaise, and hypotensive in the
ED.
.
# Fever/Pneumonia: On admission, pt found to have LLL pneumonia
likely explaining fevers with leukocytosis to 11.8. Respiratory
viral culture, CMV viral load, urine culture, and blood cultures
were all negative. Pt was started on vanc/ceftazidime which he
tolerated well. Fevers resolved and patient became
hemodynamically stable and was transferred to the floor. IV
antibiotics were changed to levofloxacin on HOD # 5 and
SOB/cough continued to improve. He was discharged on
levofloxacin to complete a total 14 day course of antibiotics.
He was provided with tesslon perels for his cough on discharge
though this had almost entirely improved.
.
# Hypotension: Pt was hypotensive upon admission to the ICU. He
met SIRS criteria with fever and leukocytosis, though was not
bacteremic. He was likely dehydrated with poor PO intake in the
days leading up to admission, along with possible adrenal
insufficiency in setting of chronic steroids. He was fluid
resuscitated with 4L NS in the ED and given Hydrocortisone 100
mg IV. He was given antibiotics as above, and his lactate
decreased from 2.1 on admission to 1.2 the next day. He was
switched back to his home dose of Prednisone 3 mg PO daily. His
BP steadily improved and he was restarted on his home Carvedilol
12.5 mg PO BID, which had been held on admission. He remained
normotensive upon transfer to the floor and through discharge.
.
# Diarrhea: Pt developed diarrhea on HOD #5, with up to 5 loose
BMs/day. Fecal culture and C. diff negative x2, though C. Diff
PCR was sent and pending on discharge. He was started on fluids
which were eventually stopped once PO intake improved. He was
also started empirically on PO flagyl for C. Diff which he will
continue for 14 day course. Diarrhea was much improved on
discharge with only 1 episode the morning of discharge.
.
# AOCRF: Cr was 2.1 on admission (recent baseline of ~2). Was
likely a pre-renal state given hypotension and dehydration.
Improved with fluids and PO intake to 1.2 on discharge.
.
# AML S/P double cord transplant: Stable. Continued
immunosuppression and treatment of GVHD with Prednisone and
Cellcept.
.
# GERD: Continued home Pantoprazole 40 mg PO daily.
.
# Follow up issues/Transitional:
-Patient set up with follow up with oncologist for 1 week after
discharge
-C. Diff PCR pending on discharge and should be followed
Medications on Admission:
acyclovir 400 mg PO TID
allopurinol 100 mg PO Daily
carvedilol 12.5 mg PO BID
escitalopram [Lexapro] 10 mg PO daily
furosemide 40 mg PO daily only as needed for weight gain of 3
lbs** He has not used this med in some time
gabapentin 300 mg PO TID
mycophenolate mofetil [CellCept] 500 mg PO bid
nitroglycerin 0.3 mg SL** Has not needed
oxycodone 5-10 mg PO Q4-6H prn pain** Not currently requiring
oxycontin 10 mg PO BID
pantoprazole [Protonix] 40 mg PO daily
Colace 100mg PO TID
Miralax PRN constipation
prednisone 3 mg PO daily
Sulfamethoxazole-trimethoprim 800 mg-160 mg PO MWF
ascorbic acid [Vitamin C] 500 mg PO daily
calcium carbonate 1,000 mg PO daily
cholecalciferol (vitamin D3) 2,000 unit PO daily
Aspirin 81 mg PO daily
loratadine [Claritin]
multivitamin with iron-mineral PO daily
thiamine HCl 50 mg PO daily
Discharge Medications:
1. acyclovir 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8
hours).
2. allopurinol 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
3. escitalopram 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day as
needed for weight gain greater than 3 pounds.
5. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3
times a day).
6. mycophenolate mofetil 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO
BID (2 times a day).
7. oxycodone 5 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO every 4-6 hours as
needed for pain.
8. OxyContin 10 mg Tablet Extended Release 12 hr [**Month/Day/Year **]: One (1)
Tablet Extended Release 12 hr PO twice a day.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. docusate sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID
(3 times a day).
11. prednisone 1 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY
(Daily).
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
13. ascorbic acid 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
14. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Day/Year **]: Two
(2) Tablet, Chewable PO DAILY (Daily).
15. cholecalciferol (vitamin D3) 2,000 unit Capsule [**Month/Day/Year **]: One (1)
Capsule PO once a day.
16. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
17. loratadine Oral
18. multivitamin with iron-mineral Tablet [**Month/Day/Year **]: One (1)
Tablet PO once a day.
19. carvedilol 12.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
20. Miralax 17 gram/dose Powder [**Month/Day/Year **]: One (1) PO once a day as
needed for constipation.
21. thiamine HCl 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
22. benzonatate 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day) as needed for cough.
Disp:*20 Capsule(s)* Refills:*0*
23. levofloxacin 750 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily) for 3 days: to be completed [**2187-4-9**].
Disp:*3 Tablet(s)* Refills:*0*
24. metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H
(every 8 hours) for 13 days: to be completed [**2187-4-19**].
Disp:*39 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Pneumonia
-Antibiotic associated diarrhea
Secondary:
-History of Acute Myeloid Leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 39623**],
You were admitted to the hospital for fevers and weakness. You
were found to have a pneumonia on chest XRAY, and were started
on IV antibiotics. You spent 1 night in the ICU and then got
transferred to the floor.
Your pneumonia has improved and you are tolerating oral
antibiotics well. You did develop some diarrhea which we feel
is likely related to your antibiotics. Your C. diff testing was
negative, but we would like to continue your treatment for this
given your good response.
We made the following changes to your medications:
STARTED: Levofloxacin (levoquin) 750mg by mouth once daily to be
completed [**2187-4-9**].
STARTED: Metronidazole (flagyl) 500mg by mouth every 8 hours.
You should complete your last dose on the evening of [**2187-4-19**]
Please note your follow up appointments below.
It was a pleasure participating in your care
Followup Instructions:
Department: [**Date Range **]/BMT
When: FRIDAY [**2187-4-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name **]/BMT
When: FRIDAY [**2187-4-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3310**], PA [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2187-5-2**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 5849, 2720, 4280, 2875 | [
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] | [
"624788f6-482b-4389-a2d5-db8fd9925c88"
] | [
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train_5999 | completed | bdeff4bc-c950-4901-96d7-57dc1f9623c3 | Medical Text: Admission Date: [**2201-5-20**] Discharge Date: [**2201-5-25**]
Date of Birth: [**2146-7-9**] Sex: M
Service: CT SURGERY
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year old
male with a known history of coronary artery disease, who was
transferred her from an outside hospital after a positive
stress test which was performed because of chest pain while
running. This showed a tight left anterior descending lesion
and moderate occlusion of the right coronary artery with a
normal ejection fraction. He was admitted for definitive
surgery.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hypertrophy.
MEDICATIONS ON ADMISSION:
1. Atenolol.
2. Cardura.
3. Prinivil.
4. Zocor.
5. Aspirin.
HOSPITAL COURSE: The patient underwent a coronary artery
bypass graft times three on [**2201-5-20**]. Apart from a slightly
difficult intubation, his surgery was uneventful. He was
transferred to the CSRU intubated. He was extubated later
the same day. He was transferred out to the regular floor on
postoperative day one where he remained stable.
His chest tubes were left in because of a small air leak on
postoperative day one. His chest tube and pacing wires were
discontinued on postoperative day three. His Foley was also
discontinued but had to be reinserted, probably likely due to
his benign prostatic hypertrophy. On postoperative day five,
his Foley was discontinued and he did void after it came out.
He is being discharged home today in a stable condition.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. b.i.d.
2. Lasix 20 mg p.o. q.d. for one week.
3. Potassium Chloride 20 meq q.d. for one week.
4. Cardura 8 mg p.o. q.d.
5. Zocor 40 mg p.o. q.h.s.
6. Aspirin 325 mg p.o. q.d.
7. Colace 100 mg b.i.d.
8. Percocet one to two tablets q4-6hours p.r.n.
FO[**Last Name (STitle) **]P: With primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in two
weeks, and with Dr. [**Last Name (Prefixes) **] in four weeks.
CONDITION ON DISCHARGE: Stable.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2201-5-25**] 11:24
T: [**2201-5-25**] 20:36
JOB#: [**Job Number 42015**]
ICD9 Codes: 4111, 4019, 9971 | [
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train_14243 | completed | b5a01af4-fda9-4c3e-a0dd-eda1e4e3c7ce | Medical Text: Admission Date: [**2116-3-2**] Discharge Date: [**2116-3-5**]
Date of Birth: [**2063-10-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 53 year old female
with a past medical history significant for melanoma
diagnosed in [**2115-3-28**], status post excision and radiation
therapy, Type 2 diabetes, and tobacco use who presented on
[**2116-3-2**] for repair of a scalp wound.
PAST MEDICAL HISTORY:
1. Melanoma.
2. Type 2 diabetes for three years.
3. Obesity.
4. Tobacco use.
ALLERGIES: Penicillin (rash).
MEDICATIONS: Metformin 500 mg p.o. b.i.d.
SOCIAL HISTORY: Tobacco use, less than one pack per day for
25 years, and ethanol use occasionally.
FAMILY HISTORY: Mother with hypertension, father with [**Name2 (NI) 499**]
cancer, and cousin with Type 2 diabetes.
PHYSICAL EXAMINATION: The patient is afebrile with vital
signs stable, in no acute distress. Lungs are clear to
auscultation. Heart sounds are regular with regular rate and
rhythm. Abdomen is benign. Postoperative large skin defect
on the scalp.
HOSPITAL COURSE: The patient was taken to the Operating Room
the same day for repair of scalp defect. Tissue expander was
removed. The patient also had a split thickness skin graft
placed to cover the wound. There were no complications. The
patient tolerated the procedure well. After surgery the
patient was taken to the Recovery Room where she was noted to
require 4 liters of oxygen by nasal cannula and 40% shovel
mask to maintain saturations in the high 90s. Therefore, she
was transferred to the Intensive Care Unit for over night
observation. The next day the patient was able to wean off
of the nonrebreather mask and her saturations remained in the
range of 93 to 95% on 4 liters of nasal cannula. The patient
was then transferred to the floor on postoperative day #1
where she was able to tolerate a regular diet, was ambulatory
and the pain was well controlled with Tylenol with Codeine.
The patient has receive preoperative antibiotics and she was
maintained on Vancomycin 1000 mg intravenously q. 12 hours as
prophylaxis for two drains. The [**Hospital 228**] hospital course
had been unremarkable, and therefore on hospital day #3, the
patient's drains were removed and she was discharged home
with visiting nurse services for dressing changes b.i.d.
Since the patient was allergic to Penicillin she was
discharged home with a five day course of Clindamycin after
removal of her drain and Vancomycin was discontinued. The
patient should follow up with Dr. [**First Name (STitle) **] in his office;
telephone number was provided to the patient to schedule a
follow up appointment.
DISCHARGE DIAGNOSIS:
1. Scalp wound.
2. Diabetes.
3. Melanoma diagnosed status post excision and radiation.
4. Tobacco abuse.
DISCHARGE CONDITION: Good.
DISPOSITION: Home with visiting nurses.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2116-3-5**] 10:51
T: [**2116-3-5**] 11:05
JOB#: [**Job Number 50363**]
ICD9 Codes: 5180, 4019, 3051 | [
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] | [
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] | [
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] | [
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] | [
"submitted"
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train_14315 | completed | a21fda27-0d99-45d3-8f8c-0a1656de96c3 | Medical Text: Admission Date: [**2173-9-23**] Discharge Date: [**2173-11-9**]
Date of Birth: [**2115-2-13**] Sex: M
Service: CCU
Please note that the dates previously dictated in the two
prior dictations were erroneous. The dictation dated
[**2173-10-4**] actually covers the [**Hospital 228**] hospital
course from [**2173-9-23**] through [**2173-11-3**].
The second dictation dated [**2173-10-9**] actually covers
the [**Hospital 228**] hospital course from [**2173-11-3**] through
[**2173-11-9**]. The patient will be discharged to rehab
today.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Name8 (MD) 4993**]
MEDQUIST36
D: [**2173-11-9**] 08:05
T: [**2173-11-9**] 08:06
JOB#: [**Job Number 44902**]
ICD9 Codes: 5845, 4280 | [
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] | [
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] |
train_10392 | completed | f6f3f557-ae36-4ca8-83bd-6abee2f9666c | Medical Text: Admission Date: [**2119-3-8**] Discharge Date: [**2119-3-26**]
Service: Cardiothor
CHIEF COMPLAINT: Transfer from outside hospital. Shortness
of breath.
HISTORY OF PRESENT ILLNESS:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2119-3-26**] 11:03
T: [**2119-3-27**] 13:12
JOB#: [**Job Number 16870**]
ICD9 Codes: 4280, 4168, 2768 | [
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] | [
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] | [
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] | [
1
] | [
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] | [
"submitted"
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train_10407 | completed | 7d2e8291-e48e-4836-8e62-790c55bbd027 | Medical Text: Admission Date: [**2164-9-10**] Discharge Date: [**2164-9-19**]
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CHF; Critical AS
Major Surgical or Invasive Procedure:
[**2164-9-12**] AVR (25 mm [**Company 1543**] Mosaic Ultra porcine))/Coronary
Artery Bypass Grafting x 2 (LIMA to LAD, SVG to PDA)
[**2164-9-14**] Mediastinal exploration for bleeding
History of Present Illness:
[**Age over 90 **]yo male with known critical AS(0.6cm2) known to service since
[**Month (only) **]. Scheduled for AVR later this month, admitted to [**Location (un) **]
with CHF, diuresed with good
resolution SOB.
Past Medical History:
Critical AS,Coronary artery disease
s/p AVR (25 mm [**Company 1543**] Mosaic Ultra porcine)/Coronary Artery
Bypass Grafting x2
CHF,Hyperlipidemia,
small bowel AVMs
,[**Company **] in [**2158**],Anemia requiring blood transfusions [**2163**],
? CAD,PAF,s/p colonscopy approximately [**2161**],BPH,s/p Bilateral
knee replacement [**2157**]. MRSA of LT knee subsequently
Social History:
Retired farmer
- Widower, wife died last year.
- Lives alone in the in-law apt at his son's house
- Has a very supportive family.
- Quit smoking 50 years ago (<5 pack year history)
- No EtOH
- No illicit drug use
Family History:
- Mother: Died at 72 secondary to an MI.
- Father: Died at 83 of old age.
Physical Exam:
Admission Physical Exam
Pulse: Resp:16 O2 sat:
B/P Right:136/82 Left:130/82
Height: Weight:
General:WDWN in NAD
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [n]few crackles at bases
Heart: RRR [x] Irregular [] Murmur4/6 SEM base
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
Pulses:
Femoral Right:2 Left:2
DP Right: 1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right: 2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
PREBYPASS
The left atrium is mildly dilated. The left atrium is elongated.
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-45%) with global
mild hypokinesis and severe hypokinesis of the inferolateral
septum.
Right ventricular systolic function is normal with good free
wall contractility.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The descending thoracic aorta
is mildly dilated. There are simple atheroma in the descending
thoracic aorta.
The aortic valve leaflets are severely thickened/deformed.
Number of leaflets cannot be determined. There is critical
aortic valve stenosis (valve area <0.5 cm2). Moderate (2+)
aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. Moderate (2+) mitral
regurgitation is seen.
There is no pericardial effusion.
POSTBYPASS
The patient is AV-paced on a phenylephrine infusion.
Left ventricular systolic function is slightly improved (LVEF =
50-55%) with some septal dyskinesis consistent with ventricular
pacing.
The new bioprosthetic aortic valve is well-seated without
perivalvular leaks or aortic regurgitation. Peak/mean gradients
across the new valve are 14/9 mmHg.
Mitral regurgitation is now mild (1+).
The thoracic aorta is intact.
Dr. [**Last Name (STitle) **] was informed of the results at the time of the
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician
[**2164-9-18**] 04:50AM BLOOD WBC-6.7 RBC-3.19* Hgb-9.8* Hct-27.8*
MCV-87 MCH-30.6 MCHC-35.1* RDW-16.7* Plt Ct-207
[**2164-9-17**] 01:18AM BLOOD WBC-9.6 RBC-3.31* Hgb-10.3* Hct-29.0*
MCV-88 MCH-31.1 MCHC-35.4* RDW-16.7* Plt Ct-184
[**2164-9-17**] 01:18AM BLOOD PT-13.4 PTT-28.9 INR(PT)-1.1
[**2164-9-15**] 03:14AM BLOOD PT-15.1* PTT-38.9* INR(PT)-1.3*
[**2164-9-18**] 04:50AM BLOOD Glucose-97 UreaN-35* Creat-1.3* Na-132*
K-3.6 Cl-96 HCO3-27 AnGap-13
[**2164-9-17**] 01:18AM BLOOD Glucose-103* UreaN-26* Creat-1.5* Na-132*
K-3.7 Cl-96 HCO3-25 AnGap-15
[**2164-9-16**] 03:08AM BLOOD Glucose-103* UreaN-24* Creat-1.4* Na-132*
K-4.2 Cl-100 HCO3-25 AnGap-11
[**2164-9-18**] 04:50AM BLOOD Mg-2.3
[**2164-9-17**] 01:18AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9
[**2164-9-10**] 07:20PM BLOOD TSH-46*
[**2164-9-11**] 09:25PM BLOOD Free T4-0.56*
Brief Hospital Course:
Admitted on [**9-10**] to complete pre-op w/u.Underwent surgery with
Dr. [**Last Name (STitle) **] on [**9-12**]. transferred to the CVICU in stable
condition on titrated phenylephrine and propofol drips. Low dose
epinephrine drip started that evening. Extubated on POD #1. Had
significant amount of bloody chest tube output and was taken
back to the OR on POD 2 for mediastinal exploration. He
remained hemodynamically stable and tolerated the procedure
well. He was again transferred to CVICU for recovery.
POD 1 from re-exploration found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker was initiated
and the patient was gently diuresed toward the preoperative
weight. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were
discontinued without complication. Labs demonstrated
hypothyroidism, endocrine consult was called and the patient was
started on levothyroxine. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 7 and 5, the wound
was healing and pain was controlled with oral analgesics. He
was deconditioned and it was decided to send him to rehab on
discharge. The patient was discharged to [**Hospital3 **] in
good condition with appropriate follow up instructions.
Medications on Admission:
AMIODARONE 200mg once a day
LASIX 20mg in AM and at noon
KCL 10mEq daily
IRON 325mg daily
pravachol 10 mg daily
Multivitamin daily
FINASTERIDE 20mg daily
omperazole 20 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q8H (every 8 hours).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours).
16. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
17. Outpatient Lab Work
Draw TSH, free T3 and free T4 on [**2164-9-26**], copy results to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 11376**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68789**] ([**Last Name (un) 16844**]) - [**Location (un) 1157**]
Discharge Diagnosis:
Critical AS,Coronary artery disease
s/p AVR /cabg x2
CHF,Hyperlipidemia,h/o esophageal
[**Last Name (LF) 75319**],[**First Name3 (LF) **] in [**2158**],Anemia requiring blood transfusions [**2163**],
? CAD,PAF,s/p colonscopy approximately [**2161**],BPH,s/p Bilateral
knee replacement [**2157**]. MRSA of LT knee subsequently
Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg -Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Thursday [**10-11**] @ 1:00 pm
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**1-28**] weeks [**Telephone/Fax (1) 11376**]
Cardiologist Dr.[**Last Name (STitle) 41990**] on [**10-4**] at 10:00 AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Draw TSH, free T3 and free T4 on [**2164-9-26**], results to Dr.
[**Last Name (STitle) **] [**Telephone/Fax (1) 11376**]
Completed by:[**2164-9-19**]
ICD9 Codes: 4241, 5119, 4280, 2859 | [
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train_10492 | completed | e430b7e8-ed13-4d51-a21e-643e6b5b4bdf | Medical Text: Admission Date: [**2185-11-9**] Discharge Date: [**2185-11-16**]
Date of Birth: [**2146-11-4**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 39 year old
male with past medical history of hypercholesterolemia who
presents from an outside hospital with the worst headache of
his life. He states the headache started very suddenly at
2:30 p.m. and was located initially in the posterior aspect
of the head radiating into his neck. It quickly spread over
the entire head and it was accompanied by nausea and severe
photophobia. The patient took Ibuprofen and tried to sleep,
unable to secondary to the pain. He went to an outside
hospital where head CT was negative but lumbar puncture
showed 136,000 red cells in tube two and 222 white cells in
tube four and 146,000 red cells. No xanthochromia. The
patient denied recent fever, cough, chest pain, shortness of
breath, weakness, numbness, tingling or vomiting.
MEDICATIONS ON ADMISSION: The patient was on Lipitor.
ALLERGIES: None.
PHYSICAL EXAMINATION: On examination, the patient is awake,
alert and oriented times three. Vital signs are stable. His
blood pressure was 137/80. His pupils are equal, round and
reactive to light and accommodation. Extraocular movements
are full. No nystagmus. Visual fields were full. His
cranial nerves II through XII are intact. He had no drift.
Speech and repetition were intact. His strength and
sensation in his extremities were intact throughout. His
toes were downgoing.
HOSPITAL COURSE: He was admitted and had an angiogram which
was negative for aneurysm bleed. He also had magnetic
resonance imaging of the head and neck which was also again
negative for any vascular malformation or presence of
bleeding. He was monitored in the Intensive Care Unit for
several days and kept on close neurologic observation. He
was transferred to the regular floor to the Step-Down Unit on
[**2185-11-11**]. He remained neurologically intact. He then had
a repeat angiogram done on [**2185-11-15**], which again was
negative for any aneurysm or vascular malformation and the
patient was discharged on [**2185-11-16**], in stable condition
with follow-up with Dr. [**Last Name (STitle) 1132**] in two weeks.
MEDICATIONS ON DISCHARGE:
1. Lipitor 10 mg p.o. daily.
2. Percocet one to two tablets p.o. q4hours p.r.n.
3. Colace 100 mg p.o. twice a day.
CONDITION ON DISCHARGE: His condition was stable at the time
of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2185-11-16**] 12:10:21
T: [**2185-11-18**] 09:00:39
Job#: [**Job Number 59515**]
ICD9 Codes: 2720 | [
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train_13264 | completed | 42eaa71a-e685-4ec7-b25d-0889f77a1190 | Medical Text: Admission Date: [**2199-10-5**] Discharge Date: [**2199-10-9**]
Date of Birth: [**2149-1-7**] Sex: M
Service: MEDICINE
ADDENDUM: Of note, on admission the patient's creatinine was
1.3, which trended upward the following day to 1.6. Due to
the patient's significant abdominal distention, tension, an
intra-abdominal pressure was transduced, which was found to
be elevated at 25. Thus it was hypothesized that the
increased creatinine could be secondary to a pre-renal-type
process of abdominal compartment syndrome, thus making the
assumption that the increased abdominal pressure was
compressing the inferior vena cava, thus decreasing flow to
the kidneys.
The patient received both TIPS and a large-volume
paracentesis on [**10-7**], which decompressed the abdomen.
The day following TIPS, [**10-8**], the patient's creatinine
normalized to 1.0, thus supporting the abdominal compartment
theory for the elevated creatinine.
No other steps were taken to normalize renal function. The
patient's urine output also improved from 5 to 20 cc/hour to
greater than 30 per hour post-TIPS and paracentesis.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-ADP
Dictated By:[**Male First Name (un) 32816**]
MEDQUIST36
D: [**2199-10-9**] 23:55
T: [**2199-10-9**] 02:25
JOB#: [**Job Number 26434**]
ICD9 Codes: 5849, 2765 | [
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train_12296 | completed | 0d4df0d7-c8b8-4ff4-966e-dd57593a3503 | Medical Text: Admission Date: [**2161-4-8**] Discharge Date: [**2161-4-15**]
Date of Birth: [**2095-7-23**] Sex: M
Service: MEDICINE
Allergies:
Gentamicin / clindamycin / Iodine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Endocarditis septic shock [**3-18**] MRSA bactermia, transfer for ICD
lead removal
Major Surgical or Invasive Procedure:
Removal of Implantable Cardioverter Difibrillator
History of Present Illness:
65 yo M with Hx of CAD with inferior MI (95) c/b post-infarction
VSD urgently repaired at same time of single vessel bypass (SVG
to RCA), recurrent VSD s/p repair, then out-of-hospital V Fib
arrest (successfully resucitated) s/p additional single vessel
bypass surgery (LIMA to LAD), additional VSD repair with
residual shunting, and implantation of ICD. Additionally,
patient has a hx of paroxysmal AFib/Flutter and is s/p
successful electrical cardioversion on [**2161-3-18**] performed [**3-18**]
worsening heart failure symptoms.
.
He presented to [**Hospital 732**] [**Hospital 107**] Hospital in [**Location (un) 90158**], NY on
[**2161-3-29**] with complaints of fever, chills, and cough X 3 days. He
was found to have a leukocytosis (16) with impressive bandemia
(27), anion-gap metabolic acidosis, hypotension, possible PNA
and AOCKI.
.
Ultimately the patient developed septic shock secondary to MRSA
bacteremia with subsequent multi-organ failure requiring
hemodialysis. He was treated with Vancomycin and Rifampin
without clearance of blood cultures, and continued to experience
rigors. TEE revealed a vegetation attached to the lead closest
to the interatrial septum (within the RA) and a second
vegetation as the lead crosses the tricuspid valve. He initially
required dopamine and levophed for hypotension, and intermittent
BiPAP ventilation. Per report, he was shocked inappropriately
multiple times for runs of SVT and rapid A Fib, so he was
started on IV Amiodarone (now transitioned to oral).
The patient was transferred to our facility for ICD lead
extraction and management of his MRSA endocarditis.
.
Currently the patient reports he feels alright. He is without
chest pain, and his dyspnea is improving. He is having
persistent hiccups.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for + dyspnea on exertion,
paroxysmal nocturnal dyspnea, LE edema, and intermittent
palpitations. Also absence of chest pain, orthopnea, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes II, +Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: X 2
-VSD s/p repair X 2 with reported residual leaking
-PERCUTANEOUS CORONARY INTERVENTIONS: BMS to LCx and LAD
-PACING/ICD: ICD placement in 90s, replacement in [**2160**]
3. OTHER PAST MEDICAL HISTORY:
-Obesity
-Chronic Kindey Injury (baseline 2.2-2.6)
-Gout
Social History:
-Lives alone in apartment, has 3 children all healthy
-Tobacco history: non-smoker
-ETOH: occasional use of ETOH ([**4-17**] drinks on weekends)
-Illicit drugs: none
Family History:
-Father died of MI at age of 69.
Physical Exam:
ADMISSION PHYSICAL:
VS: T=97.4 BP=102/62 HR=89 RR=22 O2 sat= 96%
GENERAL: obese male, mildly tachypneic, but NAD, Oriented x3,
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, difficult to appreciate JVP given obesity and RIJ
CARDIAC: + SEM across precordium, loudest at LLSB and apex.
S1/S2, increased rate
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Inspiratory bibasilar coarse crackles bilaterally
ABDOMEN: soft, distended, non-tender. Abd aorta not enlarged by
palpation. No abdominal bruits.
EXTREMITIES: + pitting edema to thighs b/l, warm and
well-perfused
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
DISCHARGE PHYSICAL:
Tc 37.1, P: 65, BP: 120/51, RR: 21. 97% on 3L, wt 105 kg
GENERAL: obese male, NAD, Oriented x3, Mood, affect appropriate.
HEENT: sclera anicteric, moist mucous membranes
NECK: Supple, difficult to appreciate JVP given obesity, HD line
in place L neck
CARDIAC: + SEM across precordium, loudest at LLSB and apex.
S1/S2, normal rate
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB
ABDOMEN: soft, distended, non-tender, BS+
EXTREMITIES: [**3-19**]+ pitting edema of all extremities (UE, LE),
warm and well-perfused, L picc ok
Pertinent Results:
ADMISSION LABS ([**2161-4-8**]):
Chem:
GLUCOSE-102* UREA N-32* CREAT-3.9* SODIUM-131* POTASSIUM-3.8
CHLORIDE-98 TOTAL CO2-26 ANION GAP-11 CALCIUM-7.3* PHOSPHATE-3.5
MAGNESIUM-1.7
LFTs:
ALT(SGPT)-17 AST(SGOT)-25 LD(LDH)-176 ALK PHOS-62 TOT BILI-2.6*
DIR BILI-2.2* INDIR BIL-0.4 ALBUMIN-2.3*
Iron Studies:
IRON-21* calTIBC-185* HAPTOGLOB-169 FERRITIN-361 TRF-142* RET
AUT-2.0
CBC:
WBC-11.8* RBC-2.77* HGB-8.2* HCT-24.9* MCV-90 MCH-29.5 MCHC-32.7
RDW-17.5*
NEUTS-88.3* LYMPHS-7.7* MONOS-3.3 EOS-0.5 BASOS-0.2 PLT
COUNT-156
Coags:
PT-38.2* PTT-37.5* INR(PT)-4.0*
.
DISCHARGE LABS ([**2161-4-15**]):
[**2161-4-15**] 03:53AM BLOOD WBC-7.7 RBC-2.68* Hgb-8.0* Hct-23.9*
MCV-89 MCH-29.7 MCHC-33.3 RDW-18.9* Plt Ct-137*
[**2161-4-15**] 03:53AM BLOOD Glucose-101* UreaN-50* Creat-6.2*# Na-134
K-4.1 Cl-98 HCO3-23 AnGap-17
[**2161-4-15**] 03:53AM BLOOD Calcium-8.0* Phos-6.9*# Mg-2.2
[**2161-4-15**] 03:53AM BLOOD Vanco-19.3
[**2161-4-10**] 03:45AM BLOOD HBsAg-NEGATIVE
[**2161-4-9**] 06:15AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2161-4-13**] 03:28AM BLOOD ALT-12 AST-22 AlkPhos-63 TotBili-0.9
.
STUDIES:
MICRO:
- BCx ([**4-12**]): 1/6 bottles positive for GPCs
- Bcx ([**4-10**]): 1/4 bottles (anaerobic bottle) with GPC in
clusters
- Bcx ([**2074-4-7**] and [**2077-4-10**]): NGTD
- Stool C diff tox ([**4-9**] and 26): negative
- IDC lead ([**4-9**]): negative
.
Radiology:
CXR [**2161-4-8**]:
REASON FOR EXAMINATION: Heart failure in a patient with infected
ICD leads.
Portable AP chest radiograph was reviewed with no prior studies
available for comparison.
Pacemaker leads terminate in right ventricle with the second
lead not clearly seen on the current study. The right internal
jugular line tip is at the level of low SVC. Cardiomediastinal
silhouettes demonstrate prior sternotomy and mild cardiomegaly.
The evaluation of the lung parenchyma demonstrates nodular
opacities projecting over the right lung that might represent
unusual appearance of pulmonary edema, but infectious process
would be a consideration. Evaluation of the patient after
diuresis is suggested and if findings persist, further
evaluation with chest CT would be highly recommended. Small
amount of bilateral pleural effusion cannot be excluded, in
particular on the left given the relatively significant distance
between the gastric bubble and the low cardiac border that might
suggest subpulmonic effusion on the left.
.
TTE [**2161-4-9**]:
Conclusions
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate global left ventricular
hypokinesis (LVEF = 30-35%). A left ventricular mass/thrombus
cannot be excluded. There is no ventricular septal defect. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. [In the setting of
at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with moderate
global LV hypokinesis. There is likely significant dyssynchrony
present. Prior VSD repair is seen in the basal septum which is
thinned and akinetic. Dilated and hypokinetic right ventricle.
Mild aortic, moderate mitral and moderate to severe tricuspid
regurgitation. No evidence of endocarditis (cannot exclude). The
LV apex is heavily trabeculated, a LV thrombus cannot be
excluded (unlikely as the apex has normal systolic function).
.
RUQ U/S [**2161-4-9**]:
IMPRESSION:
1. Non-visualization of the gallbladder. The patient will be
called back for further imaging at no additional charge by the
radiology department.
2. Normal appearance of the liver without focal liver lesions.
2. Splenomegaly.
3. Simple cysts within the right kidney.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr. [**Known lastname **] is an 82 yo M with Hx of CAD complicated by inferior
myocardial infarction, VSD s/p repair X 3, s/p 1V CABG X 2,
multiple PCIs, V Fib arrest s/p ICD placement, as well as A
Fib/Flutter s/p recent electrical cardioversion, and chronic
kidney injury who was transferred from an outside hospital with
septic shock secondary to MRSA endocarditis for planned ICD
removal by Dr. [**Last Name (STitle) **].
.
# MRSA ENDOCARDITIS/SEPTIC SHOCK: Per report, the patient
presented to the OSH with multi-organ failure requiring pressure
support and intermittent BiPAP. He was started on hemodialysis
for oliguric renal failure. Blood cultures grew
methicillin-resistant staphylococcus aureus for which he was
started on Vancomycin and Rifampin. TTE revealed vegetations on
ICD hardware (RA lead and lead crossing tricuspid valve) so the
patient was transferred to our facility for ICD extraction. He
underwent this procedure on [**4-9**], which went well. He was
extubated quickly and only required small amounts of Levophed
transiently for pressure support. TEE did not reveal clear
infection of the VSD patch. Infectious Disease provided
recommendations throughout his admission. He was continued on
Vancomycin (dosed at hemodialysis). Rifampin was not started
secondary to documented resistance at the outside hospital.
Blood cultures remained negative until evening prior to
discharge back to OSH ([**2161-4-10**] one set of blood cultures grew
GPC in clusters, sensitivites and speciations pending). He will
likely need suppressive antibiosis with Doxycycline or Bactrim
for 6-12 months after 6 weeks of IV Vancomycin. Infectious
Disease here at [**Hospital1 18**] did update Dr. [**Last Name (STitle) **] regarding the
patient.
.
# ACUTE ON CHRONIC KIDNEY INJURY: Etiology most likely ATN
secondary to hypoperfusion from septic shock. Additional work-up
was negative (Renal U/S without gross abnormalities, C3/C4
normal). Patient was started on hemodialysis at the outside
hospital and continued at our facility. His temporary HD line
was re-sited to the left internal jugular vein. Given his
clinical evidence of heart failure, his volume status was
optimized by fluid removal at HD. We renally-dosed appropriate
medications and avoided nephrotoxins. Prior to discharge, we
placed a PPD which was negative and obtained hepatitis
serologies in order for screening for outpatient dialysis center
placement given his likely future need to continue treatment.
Hepatitis B and C serologies were negative and PPD read was
negative. Additionally, he was started on nephrocaps and calcium
acetate with meals. Patient should be monitored for signs of
renal recovery to determine if he can stop dialysis in the
future. Last HD session at [**Hospital1 18**] was [**2161-4-14**]. He will likely need
HD tomorrow ([**2161-4-16**]) and should have a nephrology consult to
help facilitate this process. Vancomycin should be dosed with
HD.
.
# HYPOXIA: Likely etiology is pulmonary edema; however, patient
has nodular opacities on chest xray, which may be evidence of
septic emboli. The patient's gross volume overload was managed
at hemodialysis. He remained on 6L of oxygen supplementation via
nasal cannula during the day, and BiPAP for suspected
Obstructive Sleep Apnea at night.
.
# ACUTE ON CHRONIC SYSTOLIC CONGESTIVE HEART FAILURE: The
patient has a history of ischemic cardiomyopathy. Echo obtained
during this admission revealed a moderately dilated left
ventricle with moderate global LV hypokinesis, likely
significant dyssynchrony present, prior VSD repair seen in the
basal septum which is thinned and akinetic, dilated and
hypokinetic right ventricle, mild aortic, moderate mitral, and
moderate to severe tricuspid regurgitation. He appeared grossly
volume overloaded with rales and significant pitting anasarca.
We attempted to initiate beta-blocker therapy for better rate
control (see below); however, the patient began to have episodes
of asymptomatic bradycardia to the 30s. We did not initiate an
ace-inhibitor given his current renal function and unclear
future course. The patient had volume removed during
hemodialysis.
.
# CORONARY ARTERY DISEASE: The patient has a Hx of inferior
myocardial infarction complicated by ventricular septal defect
status post three repairs, as well as 2 single-vessel bypass
grafts (SVG to RCA, and LIMA to LAD), as well as multiple PCIs.
There was no evidence to suspect acute coronary syndrome during
this admission. We continued him on Aspirin 325 daily and
Atorvastatin 80 daily.
.
# ATRIAL FIB/FLUTTER: The patient presented with a history of
Atrial Fibrillation for which he had a successful electrical
cardioversion performed on [**2161-3-18**]. Per report, the patient had
been receiving inappropriate shocks by his ICD for runs of SVT
and AF with RVR. He was started on Amiodarone, which we
continued. During this admission he remained in coarse atrial
fibrillation and atrial tachycardia intermittently. He was also
started on a heparin drip for anticoagulation. He will receive
replacement ICD 6-8 weeks, because planned treatment course of
antibiotics is currently set for 6 weeks.
.
# COAGULOPATHY: Patient presented with prolonged PT and PTT.
Unclear if he had been receiving Coumadin at the outside
hospital. Coagulopathy possibly secondary to poor nutrition,
current antibiotics use, or prior liver injury. He received IV
vit K to reverse his INR prior to ICD removal. Resumed on
heparin gtt at end of [**Hospital1 18**] hospitalization with need for
resumption of coumadin at OSH when appropriate.
.
# ANEMIA: Iron studies reflected anemia of chronic inflammation
and iron depletion. The patient's stools were guaiac positive;
however, he demonstrated no signs or symptoms of acute bleeding.
He was started on pantoprazole daily. He may benefit from EPO
with hemodialysis; current plan is to hold off and consider iron
with hemodialysis. Additionally, given his cardiac history, he
was transfused one unit of packed red blood cells at dialysis.
.
# HYPONATREMIA: Based on clinical exam, likely hypervolemic
hyponatremia in etiology. Unable to obtain urine electrolytes.
Hyponatremia was mild and improved with volume removal. He never
demonstrated any mental status changes.
.
# ISOLATED DIRECT HYPERBILIRUBINEMIA: Present on admission and
resolved within two days. Other transaminases were within normal
limits and RUQ ultrasound was unrevealing; however, gallbladder
was not visualized. Likely secondary to cholestasis from
resolving sepsis. The patient had no RUQ abdominal pain to
suggest infection such as cholangitis. As gallbladder was not
visualized, a repeat abdominal ultrasound may be considered for
further evaluation.
.
# UNCLEAN URINALYSIS: Urinalysis appeared infected with pyuria
and hematuria; however, patient was making very little urine
volume. Was given two doses of ceftriaxone, which was
discontinued once culture returned negative for growth.
.
# DIARRHEA: Likely secondary to ceftriaxone, which was
discontinued. Clostridium difficile toxin assay negative.
.
FEN: Patient remained on cardiac, low Na, diabetic diet
ACCESS: Left IJ HD line, 2 PIVs, A-line for BP monitoring
PROPHYLAXIS:
-DVT ppx with pneumoboots
-Pain management with tylenol as needed
-Bowel regimen with senna and colace
CODE: Full code
COMM: patient, daughter ([**Name (NI) 402**]) @ [**Telephone/Fax (1) 90159**]
Medications on Admission:
HOME MEDICATIONS:
-Pepcid 20 daily
-Coumadin 1 daily
-Aspirin 81 daily
-Metoprolol 50 [**Hospital1 **]
-Lasix 40 PO daily
-Allopurinol 300 daily
-Levsin 0.125 daily PRN
-Glipizide XL 5 daily
-Levitra 20 daily
.
TRANSFER MEDICATIONS:
-Miconazole powder
-Lactobacillus 10 [**Hospital1 **]
-ASA 325 daily
-Protonix 40 daily
-Mupirocin 2% [**Hospital1 **] to nares
-Vancomycin 200 IV after HD
-Rifampin 300 [**Hospital1 **]
-Coumadin (no dose today)
-Heparin gtt
-Nystatin S&S
-Doxycycline 100 [**Hospital1 **]
-Insulin aspart SQ
-Amiodarone 400 daily
-Albuterol 2.5 inh q6h
-Atrovent 0.5 mg inh q6
-Acetaminophen
-Zofran
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: According to Scale
Subcutaneous ASDIR (AS DIRECTED).
2. aspirin 325 mg Tablet Sig: One (1) Tablet 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 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for itching, rash.
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily): Continue while on Dialysis.
7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Continue while on dialysis.
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous HD PROTOCOL (HD Protochol): Adjust according to
Vancomycin Trough and HD.
10. heparin, porcine (PF) Intravenous
11. Levsin 0.125 mg Tablet Sig: One (1) Tablet PO once a day as
needed for abdominal pain .
Discharge Disposition:
Extended Care
Discharge Diagnosis:
MRSA Endocarditis with infection of defibrillator
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were transfered to [**Hospital1 69**] for
an infection in you heart. You were evaluated and treated by the
cardiology service. You received removal of you Implantable
Cardioverter Defibrillator and tolerated its removal well. You
also received antibiotics for the infection of your
defibrillator and dialysis for your kidney difficulties. You
remained comfortable and stable throughout your admission. You
are being transfered to [**Hospital **] Hospital - [**Location (un) 732**] where you will
continue to recieve care for your heart infection.
The following changes were made to your medications:
-STOPPED Coumadin- this may be restarted at the transfer
hospital
-STOPPED Pepcid
-STOPPED Furosemide (lasix)
-STOPPED Allopurinol
-STOPPED Glipizide
-STOPPED Metoprolol
-STARTED Amiodarone 400 mg by mouth daily
-STARTED Heparin drip
-STARTED Pantoprazole 40 mg daily
-STARTED Insulin Sliding Scale
-INCREASED Aspirin from 81 to 325 mg daily
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2161-4-20**] at 2:30 PM
With: ULTRASOUND [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
ICD9 Codes: 5845, 2761, 4280, 2749, 412 | [
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train_12452 | completed | c1858886-132b-41b1-8397-8e2d434a6408 | Medical Text: Admission Date: [**2155-6-9**] Discharge Date:
Date of Birth: Sex:
Service:
PRIMARY DISCHARGE DIAGNOSIS:
1. Acute hemorrhage of the left basal ganglia, posterior
limb of the internal capsule.
SECONDARY DISCHARGE DIAGNOSIS:
1. Hypertension.
2. Status post renal cell cancer.
CHIEF COMPLAINT: Right arm weakness.
HISTORY OF PRESENT ILLNESS: Jr. [**Known lastname 22083**] is a 73-year-old
man with a history of hypertension, renal cell cancer,
prostate cancer who presents with new right arm and leg
weakness that started 1:30 PM the afternoon of admission.
The patient was in his usual state of health until 1:30 when
he was lying on his back trying to adjust electrical wires.
He got up, his wife noticed he was dragging his right leg.
She also noticed that he was leaning against the wall. She
gave him a cool cloth and put it in his right hand. She
notes that he took it into his left hand before putting on
his face. She then noticed that his right hand appeared to
be drooping and possibly his face on the right side was
drooping as well. The patient denies any headache or neck
pain at the onset of this attack. He denies any change in
vision or numbness or loss of proprioception of right arm or
leg. His wife also reports that he did not seem to be
pronouncing his words clearly as before with slight slurring
of his speech but that he was no make any speech errors and
that his sentences were meaningful and without errors.
He also did not have any noticeable loss of comprehension.
At first Mr. [**Known lastname 22083**] was weak, unable to stand up. Over
the first 20 minutes he felt his right leg becoming weaker,
could no longer stand. EMS was called, he came to the [**Hospital1 1444**] for evaluation.
On arrival to the emergency department his blood pressure was
226/124, he was given Labetalol 20 mg intravenous times two
which decreased his blood pressure to 161/90. He was
afebrile. Other vital signs were unremarkable. He was sent
for Stat Head CT, Neurology was called.
PAST MEDICAL HISTORY: As above. Hypertension, renal cell
cancer, status post right nephrectomy 6 to 10 years ago,
prostate cancer found on biopsy, status post XRT on Lupron.
MEDICATIONS:
1. Lupron q three months, next is due [**2155-6-10**].
2. Hydrochlorothiazide unknown dose.
3. Norvasc 50 mg q day.
4. Aspirin one a day (the patient usually forgets to
take them).
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Tobacco 20 pack year history quit 10 years
ago. Occasional alcohol,he enjoys cognac and whiskey. Lives
with his wife. Polish speaking originally but now English.
FAMILY HISTORY: Positive for stroke in his brother at age
67.
REVIEW OF SYSTEMS: Reports no fever, chills, headache, neck
pain, short of breath, chest pain, nausea, vomiting, vertigo,
change in vision, melena, bright red blood per rectum,
dysuria.
PHYSICAL EXAMINATION: Temperature 97.7, pulse 60 to 74,
blood pressure 226/129 on arrival, decreased to 161/90 with
Labetalol 20 mg intravenous. Respiratory rate 18. Pulse
oximetry 99% on two liters nasal cannula.
General: Well appearing man awake but somewhat sleep and in
no acute distress. His head is normocephalic, atraumatic.
Eyes; Nonicteric. The oropharynx are clear and mucous
membranes are moist. Neck supple, no carotid bruits. His
lungs are clear to auscultation bilaterally. Cardiovascular
exam is normal S1 and S2 with a negative rate. No murmurs,
rubs or gallops were appreciated. Abdomen is soft,
nontender, nondistended. Normal bowel sounds. Legs were
without edema and 2+ pulses in all four extremities.
Neurologic exam: Mental status, oriented to person, place
and day, date, month and year. Speech is fluent but with
mild dysarthria. Naming was intact to common words but
difficult to assess naming of low frequency words due to
language barrier. Mr. [**Known lastname 22083**] was able to name fairly
infrequent words in Polish according to his family. He
follows commands well. Cranial nerves: Pupils are 4 mm
bilaterally going to 2 mm bilaterally, reactive to light.
His visual acuity is 20/200 without glasses both eyes.
Visual fields were intact to confrontation. His extraocular
movements were full. Discs had sharp margins with no
appreciable hemorrhages, no nystagmus. V1 to V3 was intact
to light touch but cold to pinprick, decreased on the right
face. He had a mild right facial droop. Hearing was intact
to finger rub bilaterally. Palate was upgoing and symmetric.
Sternocleidomastoid was [**3-30**] bilaterally. His tongue was
midline with normal movements. Motor exam: He had normal
tone and bulk with no adventitious movements. Left side he
had 5/5 strength in the upper and lower extremities. On the
right side he had 4/5 strength in the deltoids, [**3-30**] in the
biceps, 4+/5 in the triceps. 4+/5 in the sensory. [**3-30**] in
the wrist flexors. [**2-28**] in the finger extensors, [**3-30**] in the
finger flexors. He had 4-/5 in the iliopsoas, hamstrings
were 4+/5, quadriceps [**3-30**], tibialis anterior was [**3-30**].
Gastrocnemius was [**3-30**]. Toe extensors were [**3-30**] and toe
flexors were [**3-30**].
Sensory exam: Sensation was decreased to light touch,
pinprick and right arm and leg compared to the left. Joint
position sense was intact in all four extremities.
Proprioception was intact in all four extremities. Reflexes
on left side of the body were 2+ throughout with downgoing
plantars. Reflex on the right side was 3+ throughout except
the Achilles tendon which was 2+ and he had upgoing toe.
Coordination, finger-to-nose testing intact bilaterally.
Alternating movements were normal. Gait was not assessed.
ADMISSION LABS: White blood count 6.0, hematocrit 33.6,
platelets 276, INR 1.2 PTT 23. Sodium 141, potassium 4.2,
BUN 28, creatinine 1.2. Glucose was 106. CK 363. MB 12.
Index 3.3. Troponin was negative times three. LFTs
unremarkable. Non-contrast head CT showed acute hemorrhage
at the left basal ganglia, posterior limb of the internal
capsule, there is mild brain atrophy with no midline shift.
HOSPITAL COURSE: Mr. [**Known lastname 22083**] was admitted to the
Neurological Intensive Care Unit on [**2155-6-9**]. He was
transferred to the floor on [**6-10**] when his neurologic exam
remained unchanged and his blood pressure had stabilized in a
range of 121 to 146/60's on oral medications.
On the 17th he had a speech and swallow exam which was
evaluated as normal.
Chest x-ray on the 18th showed a infiltrate in the left lower
lobe. The patient was put on aspiration precautions. The
follow-up chest x-ray showed a small progression of
infiltrate in the left lower lobe and a new infiltrate in the
right lower lobe however, his speech and swallow study
performed later in the day was again within normal limits.
The patient was started back on food without any incidents.
Urinalysis performed at this time revealed beginning signs of
urinary tract infection. The patient was started on
Levofloxacin and then on the following day, chest x-ray had
progressed, Flagyl was added. Both of these are to be
continued for a seven day course.
Over the weekend Mr. [**Known lastname 22083**] continued to make small gains
in his fractionation and strength. His pulmonary exam
continued to reveal no active signs of infection. However,
he did develop some diarrhea after starting the antibiotics.
C. diff cultures were sent and are negative, pending at this
time.
Magnetic resonance scan with Gadalidium was performed, which
showed focal lesion consistent with a bleed and some abnormal
edema surrounding this area, this will need to be followed up
with a repeat scan with Gadalidium in six weeks to further
evaluate.
Mr. [**Known lastname 22083**] will be discharged either today, [**2155-6-17**] or the
following day [**2155-6-18**] to a rehabilitation facility. He will
follow-up with myself, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] after
repeat magnetic resonance scan has been performed in six
weeks. He will continue on his Ciprofloxacin and Flagyl to
continue a 7 day course.
Note, I will add an addendum with the address of the
rehabilitation facility to which Mr. [**Known lastname 22083**] will be
transferred as soon as it is known.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7499**]
Dictated By:[**Last Name (NamePattern1) 22084**]
MEDQUIST36
D: [**2155-6-16**] 14:40
T: [**2155-6-16**] 15:00
JOB#: [**Job Number 22085**]
ICD9 Codes: 431, 5070, 5990, 4019 | [
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train_11832 | completed | 8abbf64f-e3a6-40f2-9043-6cf98eae5c07 | Medical Text: Admission Date: [**2203-6-27**] Discharge Date: [**2203-7-4**]
Date of Birth: [**2168-10-6**] Sex: F
Service: MED
Allergies:
Insulin Pork Purified / Insulin Beef / Erythromycin Base /
Codeine / Aspirin / Compazine
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
: The patient is a 34 year old female with Type I diabetes
mellitus, complicated by neuropathy, nephropathy, retinopathy,
and gastroparesis. She has had <i>multiple previous MICU
admissions for diabetic ketoacidosis</i>; her most recent
admission was from [**5-15**] until [**5-18**]. She states that three days
ago, she noted onset of headache and nausea. She also recalls
feeling ??????warm,?????? but did not take her temperature. Today, she
began to have nausea and vomiting, and worsening of her headache
symptoms. Her headache is aggravated by light exposure and
movement. She reports compliance with her insulin regimen
(Lantus 22 U qhs and HISS), and notes that her BS range 82-245.
Her BS were in the 200s yesterday. She denies abdominal pain,
cough, and dysuria, but she does report chronic watery diarrhea
(for which she takes loperamide). She also notes chest pressure
associated with her vomiting.
In the ED, the patient had a low grade temperature 99.8, and
was initially hypertensive (203/104). Her physical examination
was notable for unkempt appearance, a harsh 3/6 systolic
ejection murmur at the LUSB, and a R foot ulcer. She appeared
uncomfortable and had blood-tinged vomitus. Her laboratory data
was notable for a glucose of 427, an AG=20, and urine ketones.
A R subclavian line was placed. She was administered
antiemetics, IVF, and an insulin drip. Given her complaints of
headache, a head CT was done, which revealed no evidence of an
acute bleed. An LP was also done to r/o meningitis.
Past Medical History:
1. Diabetes mellitus type 1, diagnosed at age 7. The patient
has had multiple episodes of diabetic ketoacidosis in the past.
Her DM is complicated by <b>neuropathy, nephropathy, and
retinopathy.</b>
2 Chronic renal insufficiency, with baseline creatinine between
2.4 and 2.9.
3 History of gastroparesis, with episodes of nausea and
vomiting.
4. Atypical chest pain.
5. Hypertension.
6. Asthma.
7. Chronic right foot ulcer being followed by Dr. [**Last Name (STitle) 108352**] of
[**Last Name (STitle) **].
8. Chronic diarrhea.
9. Recurrent pyelonephritis.
10. ECHO [**3-6**]: <b>EF 75%</b>. No WMA/valvular abnormalities.
Social History:
The patient lives in [**Location 686**] with her fianc??????. Her PCP is
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Per his OMR note, her children have recently
been taken by DSS, hence they no longer live with her. She has
a long history of medical noncompliance.
She notes that she smokes 2 packs of cigarettes every 5 days.
She has smoked for the past 7 years. She denies use of alcohol
or illicit drugs.
Family History:
Father with type 2 DM
Physical Exam:
Gen: NAD, A& O X 3
Heent: EOMI, PEERL, MMM
Neck: no JVD
Heart: 3/6 SEM
Lungs: CLear
Abd: benign
Ext: R foot ulcer no signs of inflammation
Neuro: no more neck stiffness or Brudzenski's sign, otherwise
nonfocal
Pertinent Results:
[**2203-7-1**] 04:06AM BLOOD WBC-10.2 RBC-3.21* Hgb-9.2* Hct-28.9*
MCV-90 MCH-28.8 MCHC-32.0 RDW-16.0* Plt Ct-437
[**2203-6-30**] 03:51AM BLOOD Neuts-76.4* Lymphs-19.0 Monos-3.1 Eos-1.2
Baso-0.2
[**2203-7-1**] 04:06AM BLOOD Plt Ct-437
[**2203-6-28**] 04:19AM BLOOD Ret Man-1.0
[**2203-7-1**] 04:06AM BLOOD Glucose-93 UreaN-21* Creat-3.7* Na-141
K-4.3 Cl-106 HCO3-26 AnGap-13
[**2203-6-30**] 03:51AM BLOOD CK(CPK)-34
[**2203-6-30**] 03:51AM BLOOD cTropnT-<0.01
[**2203-7-1**] 04:06AM BLOOD Calcium-7.7* Phos-4.5# Mg-2.2
[**2203-6-28**] 04:19AM BLOOD calTIBC-270 Ferritn-66 TRF-208
[**2203-7-1**] 04:06AM BLOOD PTH-451*
[**2203-6-29**] 09:05PM BLOOD Type-ART Temp-37.3 pO2-83* pCO2-36
pH-7.44 calHCO3-25 Base XS-0 Intubat-NOT INTUBA
Brief Hospital Course:
1) DKA: Etiology likely due to medical non-compliance
(hemoglobin A1C in [**Month (only) 958**] ??????04 was 11.2) and infection
(meningitis). ruled out possibility of cardiac ischemia given
patient??????s complaint of ??????chest pressure?????? with vomiting.
AG closed and pt started POs and was swtiched from IV insulin to
Lantus.
With Lantus at 15, Blood sugars in low-upper/mid 100s.
2.Hypertension:transiently on labetolol drip eventually switched
to PO BP meds. Metoprolol increased to 75mg tid, norvasc and
lisinopril added. Lasix 40 mg po once a day was started on [**7-3**].
BP has been well controlled last few days in hospital.
3. Anemia/Crit drop:-[**6-27**] crit in afternoon was 26.4, [**6-28**]
crit in AM was 22.1 Received 2 PRBCs prior to dc and needs
followup with PCP.
4. HA/nausea on presentation to MICU: Head CT negative for acute
change. LP results c/w meningitis. Gram stain was negative for
polys/bacteria. Diagnosis of viral meningitis made and so abxs
were stopped.
5. Blood-tinged vomitius: Thought likely due to [**Doctor First Name **]-[**Doctor Last Name **]
tear and possible that patient has gastritis or an ulcer. On
[**6-29**]- GI attempted EGD but had an incomplete evaluation due to
pt refusal. Esophagitis seen in lower esophagus, stomach not
adequately inspected. No active bleeding after patient was back
on the floor. Continued the PPI. req 2 u prbcs
6. Acute renal failure on CRF:On admission suspected that ARF
secondary to prerenal azotemia in the setting of
nausea/vomiting. The patient has baseline CRI, with Cr between
2.4-2.9, now near 4.0.Renal consult fel tthis was a worsening
nephropathy, and discussed with pt possible need for HD in the
near future. ACEI started on [**6-30**] but d/c because of increasing
creatinine to >5.0. Pt was started on hecterol secondary to high
PTH likely with secondary hyperparathyroidism. Pt agreed to
followup with PCP in one week to get bloodwork drawn esp her K.
She understood risks of high potassium incl cardiac arrhythmia
and agreed to followup to get this checked.
7. Foot ulcer:
Patient is followed by [**Month/Year (2) **] who recc Wet to dry dressing
changes [**Hospital1 **].
[**6-30**]: R foot X-ray showed no osteomyelitis. Pt to f/u as
outpatient with Dr. [**Last Name (STitle) 12636**]
Medications on Admission:
1. Lantus 22 units
2. Humalog 55
3. Protonix 40 mg once a day
4. Phenergan prn
5. Atenolol 75 mg once a day
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
Disp:*QS units* Refills:*3*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Doxercalciferol 2.5 mcg Capsule Sig: One (1) Capsule PO QD
(once a day).
Disp:*30 Capsule(s)* Refills:*2*
7. Pantoprazole Sodium 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*
8. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*1*
9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
10. Humalog 100 unit/mL Solution Sig: Sliding scale
Subcutaneous Before meals and at bedtime for total of four times
a day.
Disp:*QS * Refills:*3*
11. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 4 days: Stop taking on [**2203-7-6**].
Disp:*4 Capsule(s)* Refills:*0*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days: Stop taking on [**2203-7-6**].
Disp:*12 Tablet(s)* Refills:*0*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Take before 2 pm because causes increase in urination.
Disp:*30 Tablet(s)* Refills:*0*
14. Kayexalate Powder Sig: Fifteen (15) grams PO once a day.
Disp:*300 grams* Refills:*0*
15. Outpatient Lab Work
Chem 7 electrolyte panel for Thursday [**2203-7-7**]. Please have
[**Last Name (un) 387**].
Discharge Disposition:
Home
Discharge Diagnosis:
Type 1 DM with DKA, chronic right foot ulcer, aseptic
meningitis, esophagitis, anemia, chronic renal failure, HTN
Discharge Condition:
Good
Discharge Instructions:
Pt is advised to take her medications as prescribed. Her
glucose must be checked on a regular basis and insulin
administered accordingly. She should return to the emergency
room if she experiences any nausea, vomitng, chest pain,
worsening edema, headaches, or fever/chills. Pt should follow
the Insulin sliding scale regimen as created by [**Name Initial (PRE) **]. She
should check her blood glucose before her meals and take half of
the insulin pre-meal and then recheck 2 hours after the meal for
added insulin needs.
Followup Instructions:
Patient needs to follow up with the following docotors and
outpatient clinics. The phone numbers and names will be give
and she should call to set up appointment that are most
convenient for her.
1. Nephrology ([**Last Name (un) **]) -[**2203-7-13**] at 9 am with Dr. [**Last Name (STitle) 4090**] [**Name (STitle) 4102**].
2. [**Hospital **] Clinic ([**Telephone/Fax (1) 17484**]- Needs to call to set up
appointments with [**Name6 (MD) **] DM MD, [**Name6 (MD) **] Renal MD, and dietician.
3. [**Hospital 9786**] Clinic- will need to send up appointment at a local
clinic on her own
4. [**Hospital **]- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 4335**] Where: CC-2
[**Telephone/Fax (1) 1947**] UNIT Phone:[**Telephone/Fax (1) 3153**] Date/Time:[**2203-7-19**] 3:40
5. PCP- [**First Name8 (NamePattern2) 1775**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2203-7-13**] 2:30
Please get labs drawn this week on Thursday at [**Company 191**] [**Location (un) **].
ICD9 Codes: 5849, 2761, 2851 | [
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train_11842 | completed | d9d2d3a2-a776-4d2b-a44e-983967b66484 | Medical Text: Admission Date: [**2154-3-24**] Discharge Date: [**2154-4-11**]
Date of Birth: [**2082-2-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath
CABG X 4 (SVG > LAD, SVG > Ramus>diag, SVG > PDA), Maze, [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1916**] ligation on [**2154-3-27**]
Bronchoscopy [**2154-3-29**]
Tracheostomy [**2154-4-4**]
Bronchoscopy, repositioning of trach [**2154-4-8**]
History of Present Illness:
76yo F with h/o NIDDM, HTN, lymphoma, thrombocytopenia,
transferred from OSH with chest pain. She was then transferred
to [**Hospital 1474**] Hospital, where her pain recurred at 8/10, with her
EKG showing ST depressions in V4-6, heart rate in 140s. She
received SL NTG x 3, morphine, ASA 325, Plavix 300mg, metoprolol
and IV heparin, and was transferred to [**Hospital1 18**] for consideration
of cath.
Past Medical History:
1. DM2: on oral hypoglycemics
2. Low Grade Lymphoma: recent diagnosis, pt states has not begun
treatment yet
- Per Dr. [**Last Name (STitle) 21628**] [**Telephone/Fax (1) 39201**], to start Rituxan. Can be delayed
one month if needed for BMS/Plavix.
3. HTN
4. CKD
Social History:
retired, lives with son
Family History:
noncontributory
Physical Exam:
vitals- T 98.0, HR 54, BP 105/51, RR 15, O2sat 96% 4LNC, wt
190lbs
General- elderly woman in NAD, depressed affect
HEENT- sclerae anicteric, dry MM
Neck- no JVD visible, no carotid bruits
Lungs- bibasilar rales
Heart- irregularly irregular, no murmur
Abd- obese, soft, NT, ND, NABS
Ext- 2+ pitting edema to 1/2calf b/l, DP pulses faint b/l
Neuro- alert and oriented x 3
Pertinent Results:
[**2154-4-11**] 02:41AM BLOOD WBC-16.0* RBC-2.73* Hgb-8.4* Hct-24.9*
MCV-91 MCH-30.8 MCHC-33.8 RDW-20.2* Plt Ct-26*#
[**2154-4-1**] 10:14AM BLOOD Neuts-56 Bands-0 Lymphs-5* Monos-37*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* Hyperse-1*
[**2154-4-11**] 02:41AM BLOOD Plt Ct-26*#
[**2154-4-11**] 02:41AM BLOOD PT-19.6* PTT-30.5 INR(PT)-1.9*
[**2154-4-11**] 02:41AM BLOOD Glucose-98 UreaN-112* Creat-1.7* Na-144
K-4.0 Cl-107 HCO3-26 AnGap-15
Brief Hospital Course:
Admitted from outside hospital on [**2154-3-24**]
Taken to cath lab on [**3-25**], found to have 90% LM & 2vCAD. IABP
placed, taken to the CCU. Went to the OR on [**2154-3-27**] for CABG X
4 (SVG>LAD, SVG>ramus>diag, SVG>PDA), Maze, LAA ligation,
(please see operative note for details). Post-operatively taken
to CSRU, on neo-synephrine for BP. Was slow to wean from
ventilator, due to sedation, and pulm. secretions. She had some
sinus rhythm post-op, but went back into AFib, with occasional
rapid ventricular rates. EP service was consulted, amiodarone
was started.
ID was consulted due to elevated WBC, empiric antibiotics were
started, but cultures were all essentially negative. She
remained on levofloxacin until [**2154-4-11**].
Hematology service was following her due to a new pre-operative
diagnosis of lymphoma, which ultimately was diagnosed as chronic
myelomonocytic leukemia, which will require frequent
transfusions of blood products.
She was extubated on POD # 8, but subsequently suffered a
respiratory arrest requiring brief CPR, and emergent
re-intubation.
She was taken to the OR on [**4-4**] whre she underwent tracheostomy
and PEG placement.
On [**4-8**], she dislodged her trach tube, requiring emergent
intubation, bronchoscopy, and replacement of the tracheostomy
tube.
She had a PICC line placed today for continued IV access and
possible transfusion of blood products.
She has remained hemodynamically stable and is ready to be
transferred to rehab for weaning from the ventilator.
Medications on Admission:
Prozac
Glipizide
Atenolol
Sulindac
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q4H (every 4 hours).
10. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) ML
Injection QMOWEFR (Monday -Wednesday-Friday) as needed for
chronic kidney disease.
11. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day).
15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
dose daily for INR 2.0-2.5 for AFib.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD
Atrial fibrillation with rapid ventricular response
Diabetes mellitus
Hypertension
Chronic kidney disease
Chronic myelomonocytic leukemia
Discharge Condition:
stable
Discharge Instructions:
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
Followup Instructions:
Dr. [**Last Name (STitle) **] upon discharge from rehab.
Dr. [**Last Name (STitle) 914**] in [**2-9**] weeks
PCP and oncologist (Dr. [**Last Name (STitle) 21628**] upon discharge from rehab
Completed by:[**2154-4-11**]
ICD9 Codes: 4280, 4111, 5185, 5845, 4240, 4168 | [
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train_11862 | completed | 23ea0883-587c-4ba3-9a2c-489910458b82 | Medical Text: Admission Date: [**2200-12-4**] Discharge Date: [**2200-12-17**]
Date of Birth: [**2117-2-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
[**2200-12-5**] Cardiac catheterization
[**2200-12-10**] 1. Coronary artery bypass graft x3: Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal and posterior descending
arteries. 2. Endoscopic harvesting of the long saphenous vein.
3. Aortic valve replacement with size 21 St. [**Male First Name (un) 923**] tissue valve.
4. Aortic endarterectomy.
History of Present Illness:
Ms. [**Known lastname 89480**] is an 83 year old female with a history of coronary
artery disease s/p PCI [**2190**], Diabetes Mellitus, and Atrial
Fibrillation presented to OSH with pneumonia and mild CHF
exacerbation found to have positive biomarkers. A subsequent
cardiac catheterization revealed two vessel coronary artery
disease. Cardiac surgery consulted for coronary
revascularization.
Past Medical History:
Coronary Artery Disease s/p PCI to LAD in [**2190**]
Chronic Diastolic Congestive heart failure
Hypertension
Dyslipidemia
Diabetes mellitus type 2
Chronic atrial fibrillation
Osteoarthritis
Pneumonia (3 episodes this past year)
Social History:
Race:caucasian
Last Dental Exam:6 months ago, Dr. [**Last Name (STitle) 89481**] on High St, [**Hospital1 **]
Lives with:daughter or son, widowed
Occupation:retired secretary
Tobacco:denies
ETOH:rare
Family History:
Non-contributory
Physical Exam:
Admission PE:
Pulse:72 Resp:18 O2 sat: 96%
B/P 143/56
Height: 5'5" Weight:124lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [], scattered rales
Heart: RRR [] Irregular [x] Murmur II/VI SEM
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:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:- Left:-
Pertinent Results:
[**2200-12-5**] Cath: Severe 90% LMCA stenosis, 70% RCA stenosis.
[**2200-12-8**] Carotid U/S: 1. 40-59% stenosis of the right internal
carotid artery. 2. Less than 40% stenosis of the left internal
carotid artery.
[**2200-12-10**] Echo: Pre bypass: The left atrium is moderately dilated.
There is mild symmetric left ventricular hypertrophy. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are severely
thickened/deformed. There is borderline moderate aortic valve
stenosis (valve area 1.3-cm2 on average, range 0.9- 1.6 cm2,
varies with atrial fibrillation, severe cad precludes dobutamine
stress echo) with poor mobility of left and non coronary cusps.
No aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
Post Bypass: Bioprosthetic Aortic valve in place peak gradient
5, mean 2 mm Hg. No perivalvular leaks. Preserved EF- 55%. MR
now trace to mild. Aortic contours intact. Remaining exam is
unchanged. All findings discussed with surgeons at the time of
the exam.
[**2200-12-15**] 07:53AM BLOOD WBC-8.1 RBC-3.36* Hgb-9.8* Hct-29.7*
MCV-89 MCH-29.1 MCHC-32.9 RDW-16.5* Plt Ct-124*
[**2200-12-4**] 11:05AM BLOOD WBC-11.0 RBC-4.32 Hgb-11.8* Hct-35.9*
MCV-83 MCH-27.2 MCHC-32.8 RDW-15.9* Plt Ct-355
[**2200-12-16**] 07:22AM BLOOD PT-30.4* INR(PT)-3.0*
[**2200-12-4**] 09:20PM BLOOD PT-16.1* PTT-26.3 INR(PT)-1.4*
[**2200-12-15**] 07:53AM BLOOD Glucose-148* UreaN-39* Creat-0.8 Na-134
K-4.4 Cl-98 HCO3-26 AnGap-14
[**2200-12-4**] 09:20PM BLOOD Glucose-131* UreaN-26* Creat-0.7 Na-135
K-4.3 Cl-100 HCO3-30 AnGap-9
[**2200-12-17**] 03:30AM BLOOD Hgb-9.7* Plt Ct-156
[**2200-12-17**] 03:30AM BLOOD PT-33.4* INR(PT)-3.4*
[**2200-12-16**] 07:22AM BLOOD PT-30.4* INR(PT)-3.0*
[**2200-12-15**] 07:53AM BLOOD PT-35.4* INR(PT)-3.6*
[**2200-12-17**] 03:30AM BLOOD UreaN-33* Creat-0.7
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-12-4**] for further
management of her myocardial infarction and known aortic
stenosis. She underwent a cardiac catheterization which revealed
severe left main and right coronary artery disease. An echo
demonstrated severe aortic valve stenosis. Given the severity of
her disease, the cardiac surgical service was consulted for
surgical management. She was worked-up in the usual preoperative
manner including a carotid ultrasound which showed 40-59%
stenosis of the right internal carotid artery and less than 40%
stenosis of the left internal carotid artery. Plavix was stopped
in anticipation of surgery. Dental clearance was obtained.
Heparin was continued given her chronic atrial fibrillation. On
[**2200-12-10**], Ms. [**Known lastname 89480**] was taken to the operating room where she
underwent coronary artery bypass grafting to three vessels and
an aortic valve replacement(Left internal mammary artery to left
anterior descending artery and saphenous vein grafts to obtuse
marginal and posterior descending arteries/ Aortic valve
replacement with size 21 St. [**Male First Name (un) 923**] tissue valve/Aortic
endarterectomy). Please see operative note for
details.Cardiopulmonary Bypass time=120 minutes. Cross Clamp
time= 103 minutes. On postoperative day one, she awoke
neurologically intact and was extubated without difficulty. Beta
blockade, aspirin and a statin were resumed. All lines and
drains were discontinued in a timely fashion. She continued to
progress and on postoperative day two, she was transferred to
the step down unit for further recovery. Physical therapy
service was consulted for evaluation of her strength and
mobility. She was gently diuresed towards her preoperative
weight. Coumadin was resumed for atrial fibrillation. She will
resume outpatient coumadin management as per preoperatively with
Dr. [**Last Name (STitle) 10543**]. She continued to make steady progress and was
discharged to home with VNA on postoperative day 7. All follow
up appointments were advised.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
[**Last Name (STitle) 8426**] - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg
[**Last Name (STitle) 8426**] - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
ISOSORBIDE MONONITRATE [IMDUR] - (Prescribed by Other Provider)
- 30 mg [**Last Name (STitle) 8426**] Sustained Release 24 hr - 1 (One) [**Last Name (STitle) 8426**](s) by
mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg [**Last Name (STitle) 8426**] - 1
(One) [**Last Name (STitle) 8426**](s) by mouth once a day
AVAPRO 300 mg PO daily
METFORMIN - (Prescribed by Other Provider) - 500 mg [**Last Name (STitle) 8426**] - 1
(One) [**Last Name (STitle) 8426**](s) by mouth twice a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
[**Last Name (STitle) 8426**] - 1 (One) [**Last Name (STitle) 8426**](s) by mouth every twelve (12) hours
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg [**Last Name (STitle) 8426**],
Delayed Release (E.C.) - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
WARFARIN - (Prescribed by Other Provider) - Dosage uncertain
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg [**Last Name (STitle) 8426**] - 1
(One) [**Last Name (STitle) 8426**](s) by mouth once a day
MAGNESIUM OXIDE - (Prescribed by Other Provider) - 400 mg [**Last Name (STitle) 8426**]
- 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
NIACIN - (Prescribed by Other Provider) - 500 mg [**Last Name (STitle) 8426**]
Sustained Release - 1 (One) [**Last Name (STitle) 8426**](s) by mouth once a day
Discharge Medications:
1. atorvastatin 80 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY
(Daily).
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
2. lisinopril 10 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO DAILY (Daily):
Hold for SBP<90.
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*1*
3. metformin 500 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO twice a day.
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
4. metoprolol tartrate 50 mg [**Last Name (STitle) 8426**] Sig: 0.5 [**Last Name (STitle) 8426**] PO BID (2
times a day): Hold for HR<60, SBP<90.
Disp:*60 [**Last Name (STitle) 8426**](s)* Refills:*2*
5. pantoprazole 40 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One
(1) [**Last Name (STitle) 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*60 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*1*
6. magnesium oxide 400 mg [**Last Name (STitle) 8426**] Sig: One (1) [**Last Name (STitle) 8426**] PO once a
day.
Disp:*30 [**Last Name (STitle) 8426**](s)* Refills:*2*
7. niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
9. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 * Refills:*1*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
11. Lasix 40 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO once a day for 10
days.
Disp:*10 [**Hospital1 8426**](s)* Refills:*0*
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. oxycodone-acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 [**Hospital1 8426**](s)* Refills:*0*
14. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day: INR
goal 2-2.5 for chronic AFib.
Disp:*150 [**Last Name (Titles) 8426**](s)* Refills:*2*
15. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication - Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2200-12-18**]
Results to phone fax Dr. [**Last Name (STitle) 10543**] [**Telephone/Fax (1) 4475**]
Discharge Disposition:
Home With Service
Facility:
vna [**Hospital3 **] vna
Discharge Diagnosis:
Coronary Artery Disease and Aortic Stenosis s/p Coronary artery
bypass graft x 3 and Aortic valve replacement
Myocardial infarction
Hypertension
chronic Diastolic congestive heart failure
Permanent atrial fibrillation
Dyslipidemia
Diabetes mellitus type 2
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema-Trace
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 and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1504**] [**2200-12-29**] at 1:00PM
Cardiologist/PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] [**1-8**] at 11:30am [**Telephone/Fax (1) 4475**].
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication - Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2200-12-18**]
Results to phone fax Dr. [**Last Name (STitle) 10543**] [**Telephone/Fax (1) 4475**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2200-12-17**]
ICD9 Codes: 5180, 4280, 4241, 2859, 2720 | [
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train_11875 | completed | ad5e5c29-b290-479c-8d9d-93105e268fe3 | Medical Text: Admission Date: [**2187-11-26**] Discharge Date: [**2187-12-4**]
Date of Birth: [**2129-10-22**] Sex: M
Service: General Surgery
HISTORY OF PRESENT ILLNESS: The patient with a history of
multiple debridements for peripancreatic abscess and necrosis
who was noted to have a colocutaneous fistula as well as
colonic stricture. He wished to have this corrected. Also,
he did not have his gallbladder removed.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
on [**11-26**] and underwent a cholecystectomy, an ileostomy
creation, and a colocolostomy, and partial colectomy.
Postoperatively, he was admitted to the Trauma Surgical
Intensive Care Unit. On examination, he had a blood pressure
of 110/50 and a pulse of 100. His temperature was 99.6. He
was sedated and moved all four extremities. His chest was
clear to auscultation bilaterally. He had a regular rate and
rhythm. His abdomen was soft and nontender. He had mucosa
at the ileostomy, and the extremities were warm. He was
sedated with propofol and was seen by stoma therapy. He
actually improved after his operation.
On [**11-29**], his abdomen was mildly distended. The pain
control continued to be extremely important. He did complain
at one point of some chest pain. On [**11-30**], sips were
started, and his ileostomy began to work. His diet was
advanced so that by [**12-3**] he was noted to have a
methicillin-resistant Staphylococcus aureus wound infection.
Total parenteral nutrition was stopped. He was able to
tolerate food.
On postoperative day eight, which was [**12-4**], he was
discharged to home with follow up with [**Hospital6 1587**] on an outpatient basis.
DISCHARGE STATUS: Discharge status was improved.
DISCHARGE DIAGNOSES: Colonic fistula, colonic stricture, and
pancreatitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 12891**]
MEDQUIST36
D: [**2188-2-12**] 12:51
T: [**2188-2-12**] 18:26
JOB#: [**Job Number 104131**]
ICD9 Codes: 2851 | [
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train_12773 | completed | d128d8ab-3664-4646-9f58-55e32a64a655 | Medical Text: Admission Date: [**2178-3-9**] Discharge Date: [**2178-3-13**]
Date of Birth: [**2119-11-20**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58 year old,
Chinese speaking female who developed shortness of breath on
exertion about one year ago for which she visited her PCP who
sent her for a stress test. Patient was then referred to Dr.
[**Last Name (STitle) 9779**] who recommended cardiac catheterization which patient
refused at that time. After discussing her heart condition
with her friends and family, patient was convinced that she
should now undergo cardiac catheterization. Patient reports
worsening symptoms over the past few months. Cardiac
catheterization on [**2178-1-30**] showed LM 30%, LAD 90%, PCA 90%,
RCA 50% to 99%, EF 55%.
PAST MEDICAL HISTORY: Hypertension. Asthma. High
cholesterol.
PAST SURGICAL HISTORY: Right eye laser surgery.
OUTPATIENT MEDICATIONS: Albuterol, Lipitor,
hydrochlorothiazide, metoprolol, aspirin.
ALLERGIES: No known drug allergies except for a question of
aspirin causing chest pain.
SOCIAL HISTORY: The patient has never smoked.
PHYSICAL EXAMINATION: Heart rate 57, blood pressure 113/57.
In general, patient was in no acute distress, appeared stated
age. Skin well hydrated, no rashes. HEENT pupils equally
round and reactive to light. Extraocular movements intact.
Normal buccal mucosa. No dentures. Neck supple, no JVD, no
lymphadenopathy, no thyromegaly. Chest clear to auscultation
bilaterally, no wheezes, rales or rhonchi. Heart regular
rhythm, but mildly bradycardiac, no murmurs, no rubs.
Abdomen soft, nondistended, nontender, no abnormal bowel
sounds, no guarding, rebound or rigidity. Extremities warm,
no cyanosis, clubbing or edema. No varicosities were seen.
Neuro cranial nerves II-XII were grossly intact. No sensory
or motor deficits. Pulses were 2+ bilaterally in femoral,
dorsalis pedis, popliteal and radial arteries.
HOSPITAL COURSE: The patient was admitted on [**2178-3-9**] and
taken directly to the O.R. where CABG was performed.
Postoperatively patient required Levophed and propofol drips.
Patient had chest tubes, pacing wires and perioperative
vancomycin treatment. Patient did very well postoperatively
and was extubated already on postoperative day one. She was
quickly weaned from her drips and transferred to the regular
cardiothoracic surgery floor.
On the floor the patient continued to improve. She worked
with physical therapy who indicated at this time patient is
cleared to go home. In the evening of postoperative day one,
patient experienced a decrease in urine output. She also had
a decrease in blood pressure such that volume was required.
She was acutely anemic secondary to the surgical procedure.
She received three units of packed red blood cells after
which patient stabilized and continued to thrive. Patient's
chest tubes and pacing wires were removed at the appropriate
times. She was started on beta blockers and Lasix and
isosorbide mononitrate.
On [**2178-3-13**] the patient is being discharged in good condition.
She may not drive while on pain medications. She should
avoid strenuous activity. She may take showers, but should
not take baths. She is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] in
four weeks, Dr. [**Last Name (STitle) 9779**] in two to three weeks and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in one to two weeks.
DISCHARGE MEDICATIONS:
1. Potassium chloride 30 mEq p.o. q.12 times seven days.
2. Lasix 20 mg p.o. q.d. times seven days.
3. Lopressor 12.5 mg p.o. b.i.d.
4. Isosorbide mononitrate 30 mg p.o. q.d.
5. Percocet one to two tabs p.o. q.four to six p.r.n. pain.
6. Enteric coated aspirin 325 mg p.o. q.d.
7. Colace 100 mg p.o. b.i.d. p.r.n. constipation.
8. Ranitidine 150 mg p.o. b.i.d.
9. Lipitor 20 mg p.o. q.d.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 98590**]
MEDQUIST36
D: [**2178-3-13**] 15:13
T: [**2178-3-13**] 17:42
JOB#: [**Job Number 98591**]
ICD9 Codes: 4111, 2851, 4019, 2720 | [
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train_12862 | completed | 00b9e2cd-a497-4ceb-bfad-6ac01fb588b0 | Medical Text: Admission Date: [**2103-9-14**] Discharge Date: [**2103-9-21**]
Date of Birth: [**2064-12-18**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 38-year-old
gentleman, who was positive for EtOH, fell, and had a
witnessed seizure. He was taken to an outside hospital, was
intubated, and head CT at the outside hospital revealed a
right sided bilateral frontal contusions and interparenchymal
hemorrhage. The patient was transferred to the [**Hospital1 346**] for further management.
He was admitted to the Trauma ICU. He was agitated and
confused. On post hospital day #2, he went into DTs. Was
medicated with large amounts of Ativan and Haldol. He was
moving all extremities, but not following commands at that
point.
On post hospital day #3, he was opening his eyes to voice,
was oriented to hospital. EOMs were full. Face is
symmetric. He was following commands. His IPs were full.
He had full strength in all of his extremities. He continued
to be monitored for DTs and was being weaned from his large
doses of Ativan and Haldol. Had a repeat head CT on hospital
day #2, which was stable with bilateral frontal contusions.
He was in a hard collar for suspected cervical spine injury,
however, was not awake enough to clear clinically. AP and
lateral films showed no evidence of fractures.
Transferred to the regular floor on [**2103-9-19**] with sitter.
He was cleared clinically from his hard collar on [**2103-9-21**].
He was seen by Physical Therapy and Occupational Therapy and
found to be safe for discharge home. He will need to
followup with Dr. [**Last Name (STitle) 14074**] in one month with a repeat
head CT. He had no complaints of headache or pain prior to
discharge.
MEDICATIONS AT TIME OF DISCHARGE:
1. Dilantin 100 mg p.o. t.i.d.
2. Metoprolol 50 p.o. b.i.d.
3. Percocet 1-2 tablets p.o. q.4h. prn for pain.
CONDITION ON DISCHARGE: Patient's condition was stable at
the time of discharge.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(2) 1273**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2103-9-21**] 11:04
T: [**2103-9-24**] 06:01
JOB#: [**Job Number 50344**]
ICD9 Codes: 2875 | [
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train_49607 | completed | 1e20152a-1292-4de8-b20a-21c15d7419db | Age: 57
Gender: Female
Blood Type: AB-
Medical Condition: Cancer
Date of Admission: 2023-05-31
Doctor: Shirley Armstrong
Hospital: Castaneda-Powell
Insurance Provider: Blue Cross
Billing Amount: 1821.3479464287602
Room Number: 379
Admission Type: Emergency
Discharge Date: 2023-06-25
Medication: Penicillin
Test Results: Inconclusive | [
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train_49613 | completed | 3222588b-931d-44cf-a6c8-3ecfe5ba9966 | Age: 71
Gender: Male
Blood Type: AB-
Medical Condition: Diabetes
Date of Admission: 2021-04-26
Doctor: Scott Adams DDS
Hospital: Ltd Carroll
Insurance Provider: UnitedHealthcare
Billing Amount: 11426.012130838306
Room Number: 169
Admission Type: Emergency
Discharge Date: 2021-05-04
Medication: Aspirin
Test Results: Abnormal | [
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train_49629 | completed | d4c32153-bab3-476a-8cc0-2731743f61e2 | Age: 81
Gender: Female
Blood Type: A-
Medical Condition: Arthritis
Date of Admission: 2019-12-21
Doctor: James Harris
Hospital: PLC Mack
Insurance Provider: Cigna
Billing Amount: 12093.086813733722
Room Number: 246
Admission Type: Emergency
Discharge Date: 2020-01-15
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Subsets and Splits