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train_49212 | completed | e335f9ce-51f4-4a2e-baf8-ee8ff182cad6 | Age: 23
Gender: Female
Blood Type: O-
Medical Condition: Cancer
Date of Admission: 2020-03-16
Doctor: Tiffany Frank
Hospital: and Frederick, Jones Garcia
Insurance Provider: Blue Cross
Billing Amount: 3925.9338406051947
Room Number: 333
Admission Type: Emergency
Discharge Date: 2020-03-22
Medication: Lipitor
Test Results: Normal | [
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train_49230 | completed | 9694b68c-18f6-4271-bb8d-2df4c662169f | Age: 19
Gender: Female
Blood Type: B-
Medical Condition: Asthma
Date of Admission: 2020-03-17
Doctor: Anthony Ortiz
Hospital: Carrillo-Price
Insurance Provider: Medicare
Billing Amount: 16920.16153378213
Room Number: 206
Admission Type: Emergency
Discharge Date: 2020-04-10
Medication: Lipitor
Test Results: Abnormal | [
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train_49243 | completed | 7ec3739b-5267-4459-890b-b58fb6919075 | Age: 33
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Blood Type: A-
Medical Condition: Diabetes
Date of Admission: 2023-05-30
Doctor: Sandra Powers
Hospital: Lester-Fletcher
Insurance Provider: Cigna
Billing Amount: 22257.609373733947
Room Number: 243
Admission Type: Urgent
Discharge Date: 2023-06-01
Medication: Ibuprofen
Test Results: Abnormal | [
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train_49277 | completed | cacd2c10-fd47-4da2-be02-ac739fa28928 | Age: 21
Gender: Female
Blood Type: O-
Medical Condition: Asthma
Date of Admission: 2022-01-30
Doctor: Vickie King
Hospital: Gentry and Sons
Insurance Provider: Aetna
Billing Amount: 46890.42601269252
Room Number: 307
Admission Type: Elective
Discharge Date: 2022-02-26
Medication: Aspirin
Test Results: Abnormal | [
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train_5124 | completed | a36f5caa-9cfb-4271-932b-58468720763c | Medical Text: Admission Date: [**2105-1-13**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2034-7-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Intermittent claudication
Major Surgical or Invasive Procedure:
Right femoral to above-knee popliteal artery
bypass with an 8-mm PTFE graft
History of Present Illness:
This 70-year-old gentleman is status post an
aortobifemoral bypass in the distant past for aneurysm with
occlusive disease. He has developed bilateral superficial
femoral artery occlusions with severe disabling claudication.
The left side was treated with an angioplasty. The right side
is not amenable to catheter-based intervention. Arteriography
showed reconstitution of an above-knee popliteal artery with
3-vessel runoff below the knee.
Past Medical History:
AAA with illiac artery aneurysms treated with an aortobifemoral
graft [**2089**].
Bilat carotid endarterectomies
CAD - coronary angioplasty and stenting [**2103**]
CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential
SVG to AM/PDA)[**2089**]
Hyperlipidemia
HTN
AODM
Cerebral hemorrhage mid [**2085**]??????s
Prior CVA
Social History:
Patient is married with 8 children.
Lives with: Wife
Occupation: [**Name2 (NI) **] fitter - retired
ETOH: Rare
Tobacco: denies
Family History:
non contributory
Physical Exam:
Please See H&P
Pertinent Results:
[**2105-1-13**] 06:51PM GLUCOSE-153* UREA N-19 CREAT-1.1 SODIUM-137
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2105-1-13**] 06:51PM estGFR-Using this
[**2105-1-13**] 06:51PM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-40
[**2105-1-13**] 06:51PM CK-MB-2 cTropnT-<0.01
[**2105-1-13**] 06:51PM CALCIUM-8.6 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2105-1-13**] 06:51PM HGB-11.9* HCT-35.4*
[**2105-1-13**] 06:51PM PLT SMR-VERY LOW PLT COUNT-50*
[**2105-1-13**] 06:51PM PT-14.3* PTT-30.9 INR(PT)-1.2*
[**2105-1-13**] 05:25PM TYPE-ART PO2-203* PCO2-43 PH-7.34* TOTAL
CO2-24 BASE XS--2
[**2105-1-13**] 05:25PM GLUCOSE-137* LACTATE-1.9 NA+-136 K+-4.1
CL--105
[**2105-1-13**] 05:25PM HGB-12.8* calcHCT-38
[**2105-1-13**] 05:25PM freeCa-1.15
[**2105-1-13**] 03:46PM TYPE-ART PO2-101 PCO2-32* PH-7.45 TOTAL
CO2-23 BASE XS-0
[**2105-1-13**] 03:46PM GLUCOSE-143* LACTATE-1.6 NA+-138 K+-3.9
CL--107
[**2105-1-13**] 03:46PM HGB-14.2 calcHCT-43
[**2105-1-13**] 03:46PM freeCa-1.23
Brief Hospital Course:
This 70-year-old gentleman is status post an aortobifemoral
bypass in the distant past for aneurysm with occlusive disease.
He has developed bilateral superficial
femoral artery occlusions with severe disabling claudication.
The left side was treated with an angioplasty. The right side is
not amenable to catheter-based intervention. Arteriography
showed reconstitution of an above-knee popliteal artery with
3-vessel runoff below the knee. Patient was admitted for Right
femoral to above-knee popliteal artery bypass with an 8-mm PTFE
graft.
Post-op patient was noted to be doing well with minimal pain and
stable hct.
POD1: Patient continued to do well had a small hematoma at his
groin site. DP and PT pulsed were dopplerable bilat.
POD 2: Foley was removed. Patient voided appropriately. Patient
was started on Plavix and tolerated a regular diet.
POD 3: Patient was seen by PT and cleared for home without
services.
Medications on Admission:
[**Last Name (un) 1724**]: Plavix 75', Folate-B6-B12, Gabapentin 1200', Glimepiride 1
mg', Lopressor 50', Simvastatin 80', Sitagliptin 100', ASA 81,
Niacin, Omega FA, Vit E 400'.
Discharge Medications:
1. Oxycodone 5 mg Capsule Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: otc - while on pain medication.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at
bedtime: home med.
6. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime): home med.
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
home med.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
home med.
9. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day: home
med.
Discharge Disposition:
Home
Discharge Diagnosis:
Intermittent claudication with right
superficial femoral artery occlusion.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2105-1-29**] 12:40
ICD9 Codes: 4019, 2724 | [
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train_5708 | completed | d33f694b-5cc5-47e0-9d1b-8d00824dd7e9 | Medical Text: Admission Date: [**2140-5-27**] Discharge Date: [**2140-6-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
[**2140-5-27**] [**Doctor Last Name 1352**] L3-5 PSIF Lami
History of Present Illness:
[**5-27**] [**Doctor Last Name 1352**]
[**5-27**] L3-5 PSIF Lami, 600 EBL
HPI: [**Age over 90 **] F L4-L5 spondylolisthesis with mild stenosis at
L3-4, L4-5, and L5-S1, R leg pain, amb with walker
PMH: Angina, HTN, Cholesterol, Skin Cancer, Insomnia, OA,
Restless leg syndrome, osteoperosis
MED: Fosamx 70, Atenlol 25, Aspirin 325, Nitro 0.6 mg SL,
lipitor 10, Gabapentin 100 [**Hospital1 **], Tramadol 50, Triamterene-HCTZ
37.5-25, Calcium 500-vitD, MVI
ALL: NKDA
Social History:
she lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons, two of whom live close by.
Family History:
No premature CAD, SCD
Physical Exam:
RLE pain
BLE fires L2-S1 motor
Repsonds to senstion throughout BLE
Vitals: TEMP 97.1 HR 83 BP 124/68 RR 23 SAT 96% 3L NC
Gen: Pleasant, well appearing elderly woman lying in bed in NAD
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. RR. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally. No femoral bruits.
LUNGS: L>R crackles. predominately basilar crackles on R, [**1-2**]
way up on the L. No wheezes or rales.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Gait assessment deferred
PSYCH: Mood and affect were appropriate.
Pertinent Results:
[**2140-5-27**] 02:35PM BLOOD WBC-16.6*# RBC-2.98*# Hgb-9.5*#
Hct-29.1*# MCV-98 MCH-31.9 MCHC-32.7 RDW-14.5 Plt Ct-443*
[**2140-5-30**] 06:58AM BLOOD Neuts-85.1* Lymphs-7.6* Monos-6.6 Eos-0.5
Baso-0.2
[**2140-5-27**] 02:35PM BLOOD PT-13.4 PTT-27.6 INR(PT)-1.1
[**2140-5-27**] 02:35PM BLOOD Glucose-143* UreaN-11 Creat-0.7 Na-139
K-3.4 Cl-107 HCO3-25 AnGap-10
[**2140-5-29**] 09:20AM BLOOD CK(CPK)-508*
[**2140-5-30**] 06:58AM BLOOD CK-MB-23* MB Indx-10.7* cTropnT-1.17*
proBNP-[**Numeric Identifier 4978**]*
[**2140-5-30**] 09:02PM BLOOD CK-MB-13* MB Indx-9.6* cTropnT-1.30*
[**2140-5-31**] 03:23AM BLOOD CK-MB-10 MB Indx-9.8* cTropnT-1.26*
[**2140-6-1**] 05:30AM BLOOD Calcium-8.2* Phos-1.9* Mg-1.8
[**2140-5-30**] 06:58AM BLOOD TSH-2.4
[**2140-5-31**] 03:23AM BLOOD Cortsol-21.8*
[**2140-5-27**] 02:57PM BLOOD Type-ART Temp-36.3 Rates-/12 Tidal V-500
FiO2-50 pO2-84* pCO2-42 pH-7.36 calTCO2-25 Base XS--1
Intubat-INTUBATED
[**2140-5-29**] 05:18PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2140-5-29**] 05:18PM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2140-5-29**] 05:18PM URINE RBC-[**6-9**]* WBC-[**3-4**] Bacteri-FEW Yeast-NONE
Epi-[**3-4**]
[**2140-5-29**] 05:18PM URINE CastGr-0-2 CastHy-[**3-4**]*
ECG [**2140-5-29**]: regular, narrow-complex tachycardia at 148 bpm,
left axis deviation, lateral ST-segment depression in V5-V6
compared with abseline ECG.
.
ECHO: The left atrium is mildly dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed with septal and apical akinesis
(LVEF= 25 %). Cannot exclude apical thrombus. There is distal
right ventricular free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is mild functional mitral
stenosis (mean gradient 4mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.There is moderate pulmonary artery systolic
hypertension.
.
OTHER TESTING:
CXR ([**2140-5-29**]): Single frontal view of the chest demonstrates
cardiomegaly. There is mild congestive failure with essential
prominence of the pulmonary vasculature. Aorta is somewhat
ectatic and the arch is calcified. There is left lower lobe
consolidation and a small left pleural effusion. The patient is
somewhat rotated.
.
CXR ([**2140-6-1**]): As compared to the previous radiograph, there is
unchanged moderate cardiomegaly and unchanged course and
position of the left-sided PICC line. Also unchanged is the
minimal left apical pneumothorax. The pre-existing opacity at
the left lung base is smaller and less dense than on the
previous examination. No newly occurred focal parenchymal
opacities.
Brief Hospital Course:
The patient underwent an uncomplicated procedure. She was
transfused 1 RBC. She was discharged to rehab about a routine
postop recovery. She was given written information and
precautionary guidance.
MICU Course- Patient admitted to the MICU after developing SVT,
delirium and leukocytosis on POD 3. Prior to transfer, EKG
obtained showed sinus rhythm with borderline left axis
deviation, borderline intraventricular conduction delay with TWF
in the inferolateral leads (all changes new since previous EKG
on record [**2123**]). CXR showed likely LLL infiltrate and increased
vascular markings suggestive of CHF. CE's trended with peak
troponin of 1.30, peak CK of 508 and peak MB of 37. Diagnosed
with NSTEMI vs demand ischemia. Cardiology consulted and
recommended medical management as patient could not be bolused
with heparin given recent spinal procedure. Therefore, she
could not undergo catheterization. She was started on aspirin
325mg, beta-blocker, high-dose statin. She underwent TTE on [**5-31**]
which showed EF of 25% with septal and apical akinesis.
After transferring to floor, she was taken off the heparin.
Questionable thrombus in left ventricle was evulated and thought
to be old with fibronsis over it, so patient was maintained on a
full dose of aspirin. She was not started on warfarin due to
her history of multiple falls. She remained afebrile
thoroughout her stay. Physical therapy evaluated her. It was
thought that her troponin leak is rate related and her poor EF
is due to an old MI. This post-op tachyarrhythmia revealed the
defect and cause her troponin to raise. She remained in sinus
on the floor and was discharged in stable condition. Her PICC
line was stopped and her foley was discharged. She does have a
residue small apical pneumothorax which we are following with
serial CXR. No intervention needed at this point but may need a
repeat CXR in about a week.
She has to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2140-6-13**] 10:40. She also needs to
wear TLSO brace while she is up and out of bed for the next 4
weeks. She needs to follow up with her PCP for post
hospitalization followup. Please follow up with a cardiologist
at a location near your rehab regarding further titration of
your medications.
Medications on Admission:
MED: Fosamx 70, Atenlol 25, Aspirin 325, Nitro 0.6 mg SL,
lipitor 10, Gabapentin 100 [**Hospital1 **], Tramadol 50, Triamterene-HCTZ
37.5-25, Calcium 500-vitD, MVI
Discharge Medications:
1. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GI upset.
3. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.6 mg Tablet, Sublingual Sig: [**1-2**] Sublingual
PRN (as needed) as needed for chest pain.
10. Gabapentin 100 mg Capsule Sig: [**1-4**] Capsules PO BID (2 times
a day): 200 in am, 100 in pm, 400 in evening.
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for fever or pain.
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
L3-L5 Spinal Stenosis
SVT
h/o MI
CHF
low urine output
hypotension
AMS
anemia
pneumonia
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:
Mrs. [**Known lastname 4643**], you came to the hospital for back surgery. After
surgery, you developed a very fast heart rate and arrythmia
called atrial flutter. We were able to control your heart rate
and you converted back to the regular rhythm. However,
evaluation of your heart showed that you had a previous silent
heart attack that caused a reduction in how effective your heart
pumps. We believe this is the reason for all the lab
abnormalities when your heart was beating very fast. You were
discharged in stable condition and was started on the following
new medications (see below).
Please follow up the following doctors.
Please note we made the following changes to your medications.
STOPPED:
Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
INCREASED:
1. Aspirin 81mg by mouth daily to Aspirin 325 mg Tablet Sig:
One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet PO DAILY to Atorvastatin 80 mg
Tablet Sig: One (1) Tablet PO DAILY (Daily).
STARTED:
Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Lasix 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig:
0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
It was a pleasure taking care of you. We wish you the best on
your road to recovery.
You have activity limitations:
No Bending
No Twisting
No Lifting
Please call your PCP if your weight increases >2lb in one day.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2140-6-13**] 10:40
Please follow up with your PCP and cardiologist near your rehab.
You need to have your medications titrated to appropriate
level, specifically with regard to your diuretics.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
ICD9 Codes: 486, 4280, 9971, 4019, 2859, 2720, 412 | [
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train_30361 | completed | 1e9b7e50-64eb-4be8-9feb-335aca5074b5 | Medical Text: Admission Date: [**2146-9-10**] Discharge Date: [**2146-10-5**]
Date of Birth: [**2116-6-27**] Sex: M
Service: MEDICINE
Allergies:
Cefepime / Vancomycin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Fever/rash
Major Surgical or Invasive Procedure:
Endotracheal intubation, arterial line, bilateral chest tubes
History of Present Illness:
Mr. [**Known lastname **] is a 30 y/o man w/ h/o refractory Hodgkin's lymphoma
s/p reduced intensity non-myeloablative MUD transplant [**2146-6-27**]
who was discharged the day prior to admission and who now
returns with fever and diarrhea. Mr. [**Known lastname **] was recently admitted
on the BMT service from [**9-6**] to [**9-10**] with a fever and a new
morbilliform rash. No infectious source for his fevers was
identified (chest CT was done as well as urine/blood cx NGTD;
CMV VL is still pending). He was treated empirically with
Linezolid (red man reaction with Vancomycin and allergy to
Cefepime) initially and then Abx were changed to Levofloxacin.
During his last admission, his temperature never exceeded 100.6.
He defervesced and was discharged home after being afebrile x 24
hous. Dermatology was consulted for the rash, and it was felt to
be GVHD. He was discharged on triamcinolone cream, oral
prednisone 60mg, and levofloxacin.
The evening of discharge he developed low-grade fever at home,
but then spiked to over 102 overnight. He reports that his rash
has not significantly changed and possibly is less confluent
now. He does report new onset of diarrhea that started on the
evening of discharge from the hospital. He has had 4 loose
watery non-bloody BMs with some abdominal cramping prior to BMs.
He felt weak and tired with fevers, but had no other symtpoms.
Specifically, no abdominal pain. He denies nausea, vomiting,
cough, SOB, rhinorrhea, sore throat, dysuria, headaches,
dysphagia.
In the ED, VS on presentation 101.9 (then fever to 102.2) BP
98/44 (then down to 85/45) HR 130's. Lactate initially 2.3.
Blood cx and urine cx sent. The patient received Zosyn 4.5 mg
IV, Linezolid 600 mg IV, Flagyl 500 mg IV, Solumedrol 125 mg IV,
and Tylenol PO. He was resuscitated with a total of 4L NS with
response in BP.
While on the floorhis BP was bordeline low and a diarrhea w/u
was continued. He was started on TPN on HD #2. His rash was
noted to worsen, solumedrol was added. Cont on flagyl, zosyn,
bactrim. Flagyl stopped on HD #4. Zosyn then d/c'd but then
restarted on [**9-15**] for fever to 101.4. On day of transfer, pt
with inc cough. CTA peformed and vanco added. Fluconazole
changed to voriconazole. On day of transfer, pt actuely desat'd
to mid 80's but recovered with supplimental oxygen. CTA of chest
done showed bilateral ground glass opacities. Pulm consulted for
? bronchoscopy.
Called by moonlighter at 4:30 am for hypoxia. Pt desatted and
required [**Month/Year (2) 597**]. On [**Name (NI) 597**] pt initally satting in the mid 80's.
Tachycaridic in sinus tach to 140-150's. BP stable. Afebrile.
Given 20 mg IV lasix w/ 700 cc UOP. ABG showed 7.44/33/44. He
was urgently transferred to the [**Hospital Unit Name 153**] for intubation and resp
failure. Pt was intubated with anesthesia present and then was
transiently hypotensive on sedation.
Past Medical History:
1. Hodgkin's Lymphoma, nodular sclerosing.
- Diagnosed [**2144-6-6**].
- s/p ABVD x4 cycles with good response, then ABVD x2 with poor
response.
- s/p CEP x2 with poor response.
- s/p gemcitabine/cisplatin/dexamethasone x3.
- s/p auto-SCT with Cytoxan [**9-/2145**], with persistent adenopathy
and PET +.
- s/p XRT to chest wall [**1-/2146**] followed by Rituxan/vinblastine
w/ good response.
- s/p mini-matched unrelated donor (MUD) allo transplant
[**2146-6-27**] with evidence of disease progression on CT
- s/p Gemcitabine [**2146-7-21**], last treatment [**8-11**]
- s/p DLI [**2146-8-25**].
Social History:
Worked as account manager at hedge fund, on disability now x 1
year. Denies EtOH, tobacco, illicits.
Family History:
He has a stepfather who is unrelated to him who
has non-Hodgkin's lymphoma. Father recently d. lung cancer. His
maternal grandmother with [**Name2 (NI) 499**] cancer and paternal cousin has
pancreatic cancer.
Physical Exam:
Vitals: 99.6, HR 113, 88/44, RR 21-23, AAC 100%, 400 x 20, PEEP
5
Gen: tired ill appearing young man in acute distress
HEENT: pt on [**Name2 (NI) 597**]
Pulm: CTAB. w/ distant BS, no wheezes
CV: regular, nl S1S2, no m/r/g.
Chest: Right Hickman w/o s/sx of infection
Abd: + BS, soft, NT, ND
Ext: 2+ DP, no e/c/c.
Neuro: AAOx3, no focal neuro deficits on gross exam.
Skin: diffuse erythematous rash confluent on chest and back, +
blanching, with discrete macules and papules on extremities,
abdomen, behind ears.
Pertinent Results:
LABS ON ADMISSION:
[**2146-9-11**] 12:00AM GLUCOSE-142* UREA N-8 CREAT-0.5 SODIUM-139
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
[**2146-9-11**] 12:00AM ALT(SGPT)-100* AST(SGOT)-35 ALK PHOS-54 TOT
BILI-0.3
[**2146-9-11**] 12:00AM ALBUMIN-3.4 CALCIUM-8.7 PHOSPHATE-2.4*#
MAGNESIUM-1.9
[**2146-9-11**] 12:00AM WBC-6.3 RBC-3.70* HGB-11.0* HCT-33.2* MCV-90
MCH-29.8 MCHC-33.2 RDW-20.6*
[**2146-9-11**] 12:00AM NEUTS-73* BANDS-10* LYMPHS-7* MONOS-3 EOS-1
BASOS-0 ATYPS-2* METAS-3* MYELOS-1*
[**2146-9-11**] 12:00AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-2+
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
[**2146-9-11**] 12:00AM PLT COUNT-203
[**2146-9-11**] 12:00AM PT-12.3 PTT-23.7 INR(PT)-1.1
[**2146-9-11**] 12:00AM GRAN CT-5200
[**2146-9-10**] 10:28AM LACTATE-0.7
[**2146-9-10**] 09:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2146-9-10**] 08:36AM LACTATE-2.3*
[**2146-9-10**] 08:15AM GLUCOSE-105 UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
[**2146-9-10**] 08:15AM ALT(SGPT)-82* AST(SGOT)-30 LD(LDH)-237 ALK
PHOS-58 TOT BILI-0.4
[**2146-9-10**] 08:15AM WBC-5.5 RBC-4.03* HGB-12.1* HCT-35.5* MCV-88
MCH-30.0 MCHC-34.0 RDW-21.0*
[**2146-9-10**] 08:15AM NEUTS-66 BANDS-2 LYMPHS-1* MONOS-9 EOS-12*
BASOS-0 ATYPS-3* METAS-7* MYELOS-0
[**2146-9-10**] 08:15AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-2+ OVALOCYT-2+
TEARDROP-OCCASIONAL
[**2146-9-10**] 08:15AM PLT SMR-NORMAL PLT COUNT-185
[**2146-9-10**] 08:15AM PT-12.3 PTT-23.5 INR(PT)-1.1
.
LABS ON TRANSFER TO ICU:
[**2146-9-18**] 12:00AM BLOOD WBC-5.3 RBC-3.88* Hgb-12.0* Hct-35.2*
MCV-91 MCH-31.1 MCHC-34.2 RDW-21.3* Plt Ct-192
[**2146-9-18**] 12:00AM BLOOD Neuts-60 Bands-20* Lymphs-4* Monos-9
Eos-1 Baso-0 Atyps-3* Metas-1* Myelos-2* NRBC-1*
[**2146-9-18**] 12:00AM BLOOD Plt Ct-192
[**2146-9-19**] 04:15AM BLOOD Fibrino-367#
[**2146-9-18**] 12:00AM BLOOD Gran Ct-4130
[**2146-9-18**] 10:32PM BLOOD Glucose-236* UreaN-18 Creat-0.7 Na-133
K-5.0 Cl-106 HCO3-22 AnGap-10
[**2146-9-18**] 12:00AM BLOOD ALT-104* AST-42* LD(LDH)-576* AlkPhos-61
TotBili-0.6
[**2146-9-18**] 12:00AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.0 Mg-2.0
[**2146-9-19**] 04:15AM BLOOD Hapto-212*
[**2146-9-18**] 09:31AM BLOOD Type-ART Temp-38.9 Rates-20/ Tidal V-400
PEEP-10 FiO2-80 pO2-97 pCO2-50* pH-7.30* calTCO2-26 Base XS--1
AADO2-439 REQ O2-74 -ASSIST/CON Intubat-INTUBATED
[**2146-9-18**] 04:29AM BLOOD Lactate-3.5*.
IMAGING:
[**2146-9-17**] Chest X Ray: A single AP view of the chest is obtained
on [**2146-9-17**] at 08:21 hours and compared with the prior day's
radiograph performed at 12:23 hours. When compared to the prior
day's examination, there appears to be improvement in the
minimal patchy increased density at the left base likely due to
improvement of some subsegmental atelectasis. There is patchy
increased density in the right base, which is new and which may
represent minimal airspaces and/or atelectasis. The remainder of
the lung fields appear unchanged since prior day's radiograph.
Brief Hospital Course:
Mr. [**Known lastname **] is a 30 yo male with h/o refractory Hodgkin's lymphoma
s/p reduced intensity non-myeloablative MUD allo transplant who
was admitted with GVHD rash and diarrhea who was transferred to
the [**Hospital Unit Name 153**] with hypoxic respiratory failure.
1)Respiratory Failure: The cause of Mr. [**Known lastname 63572**] respiratory
failure was thought to be secondary to the Bleomycin, which he
had received as part of his chemotherapy regimen in the past.
Cxray suggested diffuse atelectasis in addition to basilar
opacities. No source of infection was identified; all cultures
were negative. He was empirically started on Vancomycin,
Caspofungin, Bactrim, and Zosyn to cover him for all possible
organisms. He was also placed on Methylprednisolone. His
respiratory status was further complicated by bilateral PTXs,
etiology still unclear. Pt was made CMO once discussions with
the BMT and [**Hospital Unit Name 153**] team suggested that he had a poor prognosis.
All medications were stopped at the time; he was slowly weaned
off the ventilator, and he was started Morphine, Methadone, and
Fentanyl for comfort.
2) LUE DVT: Pt with spontaneous L subclavian, brachial, and
axillary non-occlusive DVT and unchanged small LLL filling
defect on chest CTA. D/w BMT team, who agreed that given this
pt's high risk of bleeding, will not treat DVT at this point
with anticoagulation.
4) Diarrhea: Most likely secondary to GVHD. Stool cultures were
negative for c.diff and overlying infectious etiology. No
further intervention was done.
5) Thrombocytopenia: Likely secondary to his underlying and
refractory malignancy. His plt remained above goal and did not
require any further transfusions.
6) Rash. Likely secondary to GVHD and possibility of red-man
syndrome secondary to Vancomycin. The rash persisted during his
[**Hospital Unit Name 153**] stay and was evaluated extensively during his prior stay.
No further evaluation was done at this time. He was continued on
steroids.
7) Hodgkin's Lymphoma, refractory to tx. Most recently s/p DLI
[**2146-8-25**]. CT [**9-8**] showed some regression of tumors. Patient was
not a candidate for further treatment. He was followed closely
by the BMT service during his stay in the [**Hospital Unit Name 153**] and until his
death.
8) FEN: Pt was maintained on TPN, which was d/c'ed once he was
made CMO.
9) PPx: Pt was placed on pneumoboots for DVT prophylaxis (since
he was not a candidate for anti-coagulation). He was also placed
on PPI for GI regimen.
10) Code status: Pt was initially full code on admission to the
[**Hospital Unit Name 153**]; his code status was then changed to CMO after multiple
discussions with the BMT team.
Pt was pronounced dead on [**2146-10-5**].
Discharge Medications:
Pt died
Discharge Disposition:
Expired
Discharge Diagnosis:
[**Last Name (un) 35473**] Lymphoma, refractory
Respiratory failure
Discharge Condition:
Pt died on [**2146-10-5**]
Discharge Instructions:
As above
Followup Instructions:
As above
ICD9 Codes: 2875, 2761 | [
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train_30451 | completed | f70f263b-7717-44db-994d-f3a313a11e1d | Medical Text: Admission Date: [**2127-8-1**] Discharge Date: [**2127-8-5**]
Date of Birth: [**2053-3-5**] Sex: F
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
PEA arrest in the ED
Major Surgical or Invasive Procedure:
Temporary pace wiring placed on [**2127-7-31**] and removed
on [**2127-8-3**]
History of Present Illness:
Prior Hospitalizations
74F with a hx of HTN, hyperlipidemia, diabetes who has recent
complicated medical admissions. In [**2127-2-25**], she had an
intracatheterization MI (clotted off LAD, LCX on [**2127-3-24**]) with
cardiac arrest and subsequent resuscitaiton requiring ECMO.
Kissing stents of the LMCA into the LAD and Lcx were deployed.
The patient course was complicated by RP bleed. Her last echo
([**2127-3-28**]) shows LVEF 30% with LV basal and mid inferior
hypokinesis with basal and mid inferolateral and lateral
akinesis.
.
The patient most recent hospitalization was [**7-17**] -[**7-24**]. During
which time she had CHF symptoms and found to have an increase PA
pressure. The patient was started on Amiodarone and instructed
to restart Toprol.
.
Current hospitalization
Pt was in usual state of health until day of admission when she
took first doses of Toprol XL (25mg) (~2PM). She began to
complain of DOE and headache and presented to the ED ~11PM on
day of admission.
.
EMS found HR to be in 50s, BP 70s/palp. In ED was given fluids,
and began to feel slightly better. Admitted to OBS. Patient then
began to brady down to 40s in junctional rhythm ultimately
requiring Atropine, then Epinephrine and transcutaneous pacing
as well as a second liter of fluid.
Cardiology consult was called and at the time of arrival,
patient had been intubated for airway protection given continued
bradycardia and hypotension. Dopamine was started with minimal
effect. During evaluation, patient went into PEA and was given
epinephrine 1mg with good effect, and pulse was reestablished.
Dopamine was run wide-open. Following initial stabilization,
patient returned to PEA, and ACLS/CPR was initiated. Patient
continued to receive epinephrine up to a total dose of 5mg as
well as glucagon, at which point she was again stabilized on
dopamine drip 20mcg.
STAT Echocardiogram following stabilization revealed:
No effusion, mild RV hypokinesis, good LV function, 2+MR.
Once the patient stabilized she was tx to the CCU.
Past Medical History:
Diabetes mellitus
Hypertension
C section
hysterectomy
mild LV systolic dysfunction at baseline
Social History:
Married, lives with her husband in [**Location (un) 686**]. No stairs.
Daughter lives on the [**Location (un) **] of her house.
Family History:
noncontributory
Physical Exam:
T 99.8 BP 97/53 P 91 RR 9 O2 sat 100%
Vent settings: AC 500 X 14 PEEP %
Gen: Opens eyes to voice, responds to commands
HEENT: IJ in place on R side of neck,
Pulm: coarse, rhonchorous bs bilaterally
Heart: reg rate, S1S2q, [**3-30**] blowing systolic murmur loudest at
apex
Abd: soft, ND, +BS
Ext: no edema, warm extremities with good pulses
Neuro: responds to commands, PERRL, downgoing toes for Babinski
Pertinent Results:
Labs on Admission
[**2127-7-31**] 11:55PM BLOOD WBC-6.2 RBC-4.18* Hgb-12.6 Hct-39.5
MCV-95 MCH-30.1 MCHC-31.8 RDW-14.0 Plt Ct-185
[**2127-7-31**] 11:55PM BLOOD PT-13.0 PTT-25.8 INR(PT)-1.1
[**2127-7-31**] 11:55PM BLOOD Glucose-236* UreaN-25* Creat-1.9* Na-139
K-4.4 Cl-104 HCO3-20* AnGap-19
[**2127-7-31**] 11:55PM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9
.
Cardiac Enzymes
[**2127-8-1**] 06:45AM BLOOD CK(CPK)-72
[**2127-8-1**] 09:30PM BLOOD CK(CPK)-48
[**2127-8-1**] 06:45AM BLOOD CK-MB-NotDone cTropnT-0.09*
.
ECHO [**2127-8-1**]
The left atrium is moderately dilated. Overall left ventricular
systolic
function is moderately depressed with focal akinesis/thinning of
the basal 2/3rds of the inferolateral and inferior walls. The
remaining segments contract well. The right ventricular cavity
is mildly dilated with severe hypokinesis of the apical 2/3rds
of the free wall. The aortic valve leaflets (3) are mildly
thickened but with good leaflet excursion. The mitral valve
leaflets are structurally normal. ?Moderate (2+) mitral
regurgitation is seen (focused views). There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
ECG [**2127-7-31**]
Junctional mechanism at rate 52 with marked Q-T interval
prolongation and
anterolateral T wave inversion. Consider drug effect, primary
CNS pathology and/or myocardial ischemia. Also noted is right
axis deviation. Compared to the previous tracing of [**2127-4-15**] the
mechanism is junctional rather than sinus, the rate is slower,
Q-T interval prolongation (borderline on the prior tracing) is
now marked, and there is new T wave inversion in leads V2-V5. T
waves are inverted in leads I, aVL and V6 on both tracings.
.
ECG [**2127-8-1**]
Compared to the previous tracing the rhythm is now sinus
bradycardia at
rate 51 rather than junctional at rate 52. Q-T interval
prolongation and
precordial and lateral T wave inversions persist. The
differential is as
before.
.
ECG [**2127-8-4**]
Sinus rhythm
Consider left atrial abnormality
Q-Tc interval appears prolonged but is difficult to measure
Consider right ventricular overload
Nonspecific T wave abnormalities
Clinical correlation is suggested
Since previous tracing of [**2127-8-3**], no significant change
Brief Hospital Course:
Course in the ED
EMS found HR to be in 50s, BP 70s/palp. In ED was given fluids,
and began to feel slightly better. Admitted to OBS. Patient then
began to brady down to 40s in junctional rhythm ultimately
requiring Atropine, then Epinephrine and transcutaneous pacing
as well as a second liter of fluid.
Cardiology consult was called and at the time of arrival,
patient had been intubated for airway protection given continued
bradycardia and hypotension. Dopamine was started with minimal
effect. During evaluation, patient went into PEA and was given
epinephrine 1mg with good effect, and pulse was reestablished.
Dopamine was run wide-open. Following initial stabilization,
patient returned to PEA, and ACLS/CPR was initiated. Patient
continued to receive epinephrine up to a total dose of 5mg as
well as glucagon, at which point she was again stabilized on
dopamine drip 20mcg.
STAT Echocardiogram following stabilization revealed:
No effusion, mild RV hypokinesis, good LV function, 2+MR.
The patient was transferred to the CCU and her course was as
follows:
1. Cor: The patient has a hx of CAD s/p kissing stents of
LAD/LCX. The patient was maintained on aspirin and plavix. The
BB and amiiodarone were initially held. The BB was later
restarted.
2. Rhythm: The etiology of the patient's PEA was unknown.
During the initial part of her course she was in a junctional
rhythm and hypotensive. An atrial pacer was placed and the
patient remained in NSR and her BP improved. The patient was
later weaned off of the dopa gtt and the pacer was removed. Her
BB and Amiodarone were held as this may have contributed to her
PEA. It was later felt that the patient's presentation was
secondary to the amiodarone. The patient was restarted on
lopressor 25 [**Hospital1 **]. Amiodarone has since been listed as one of
her allergies.
3. Pump: During the code, an emergency ECHO was performed. No
pericardial effusion was noted. The patient's EF was 35-40%.
The final report was significant for the following:
The left atrium is moderately dilated. Overall left
ventricular systolic
function is moderately depressed with focal akinesis/thinning
of the basal
2/3rds of the inferolateral and inferior walls. The remaining
segments
contract well. The right ventricular cavity is mildly dilated
with severe
hypokinesis of the apical 2/3rds of the free wall. The aortic
valve leaflets
(3) are mildly thickened but with good leaflet excursion. The
mitral valve
leaflets are structurally normal. ?Moderate (2+) mitral
regurgitation is seen
(focused views). There is moderate pulmonary artery systolic
hypertension.
There is no pericardial effusion.
After reviewing the ECHO , the patient's cardiologist
recommended MV repair. However the patient refused.
4. Airway protection: The patient was intubated strictly for
airway protection. She was later extubated once deemed
medically stable. Her O2 sats were stable on room air.
5. ARF: Creatinine increased from 1.2 to 1.4 within 48 hours.
This was attributed to ATN (ischemic assault). Her creatinine
was monitored. Her FeNa was 0.6, suggestive of a prerenal
azotemia. PO fluids were encouraged.
6. Dispo: The patient was discharged home with services and
scheduled to followup with her cadiologist, Dr. [**Last Name (STitle) 1911**],
and her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**].
Medications on Admission:
Per prior discharge summary
1. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: Take from [**7-25**].
Disp:*7 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Take from [**Month (only) 205**] onwards.
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. 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*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 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*
4. Lisinopril 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Protonix 40 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*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day: To
be taken with dinner.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bradycardia secondary to amiodarone sensitivity
Discharge Condition:
Good
Discharge Instructions:
You must call 911 immediately if you feel short of breath, have
chest pain or pressure, palpitations, pain radiating to your jaw
or numbness or tingling in your arms.
Followup Instructions:
You should follow-up with you PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**] in one week.
An appt has been made for you to see Dr. [**First Name (STitle) 1395**] on [**2127-8-12**]
at 10:30am, location: [**Apartment Address(1) 2942**],
[**Location (un) **].
You should follow-up with your cardiologist, Dr. [**Last Name (STitle) 1911**].
You have an appt with him on [**8-14**] at 1:00pm on the [**Location (un) **] of the Clinical Center on the [**Hospital Ward Name 516**].
Completed by:[**2128-8-22**]
ICD9 Codes: 4275, 5845, 2762, 4240, 4280, 4019, 412 | [
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train_29658 | completed | e7c1e2ba-c0e9-4008-b26d-1997efc83629 | Medical Text: Admission Date: [**2122-10-12**] Discharge Date:[**2122-10-14**] to
newborn nursery
Date of Birth: [**2122-10-12**] Sex: M
Service: NB
TRANSFER DIAGNOSIS: Premature male, twin number 1, 34 and
5/7 weeks gestation.
HISTORY OF PRESENT ILLNESS: The mother is a 20-year-old,
primigravida, with asthma on Albuterol. Prenatal screens
revealed her to be O positive. HB surface antigen was
negative. Group B strep is unknown. Rubella immune.
ANTEPARTUM HISTORY: Spontaneous twin gestation whose
pregnancy was complicated by gestational hypertension treated
with Labetalol. Preterm labor was treated with Magnesium
Sulfate and bedrest.
Cesarean section was done for nonreassuring fetal heart rate
tracings. There was no intrapartum fever or other clinical
evidence of chorioamnionitis.
Membranes ruptured at delivery revealing clear amniotic
fluid. Intrapartum antibiotic therapy was administered six
hours prior delivery. The infant's birth weight was 2.770
kg, and he was the large of the twins. His brother was [**Name2 (NI) **]
at 1900 g.
HOSPITAL COURSE: Respiratory: The infant remained in room
air without any issues.
Cardiac: There were no cardiac issues.
Infectious disease: Blood cultures and CBC were done at 48
hours with negative cultures. The antibiotics were
discontinued. CBC was benign.
Feeding and nutrition: On the day of transfer to the Newborn
Nursery, the infant weighed 2.800 kg, was feeding ad lib
demand and taking upwards of 74 cc/kg/day of Special Care 20
cal/oz formula.
The infant's bilirubin on [**10-13**] was 6.4/0.4.
The infant was transferred to the Newborn Nursery. Upon
discharge, he will be followed at [**Hospital1 **]
[**Location (un) 2898**] Center by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2122-10-14**] 10:29:21
T: [**2122-10-14**] 10:45:20
Job#: [**Job Number 56619**]
ICD9 Codes: V290, V053 | [
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train_30098 | completed | 8102c2cd-5505-42ee-8688-b4c1a499ead7 | Medical Text: Admission Date: [**2170-5-8**] Discharge Date: [**2170-5-14**]
Date of Birth: [**2110-11-23**] Sex: M
Service: MEDICINE
Allergies:
Sustiva
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
abdominal discomfort
Major Surgical or Invasive Procedure:
IVC filter
History of Present Illness:
60 yo male with hx DVT, HIV, Hep C, HCC,RCC with mets to lung
s/p cyberknife (last one 2 days ago) presents with epigastric
pain and chest pain, worse with swallowing. Started after
cyberknife, worse with swallowing leading to decreased POs; no
pleuritic component or SOB. In the ED, hemodynamically stable.
CTA chest with saddle PE. Echo with mild RV dilatation. Bolused
with heparin and admitted to unit for close monitoring.
Past Medical History:
HIV- Dx [**2154**]. Nadir CD4 141; last CD4 [**6-6**] 610
Exposure risk: IDU
Med Exposures: indinavir-- complicated by hematuria
efavirenz-- CNS side effects
nevirapine-- hepatotoxicity
Combivir??????anemia
ITP- s/p splenectomy [**2158**]
HCV- Dx [**2154**], Genotype 1
Bx [**3-/2167**] [**7-6**] fibrosis; [**9-11**] HAI
no therapy; EGD [**3-/2167**]- no varicies
AFP increasing
flex sig [**2165**]- Hyperplastic polyp removed from colon
DVT LLE [**9-5**]
Likely HCC ( characteristic lesions on CT at dome of liver and
elevated AFP)
RCC, metastatic to lung, dx [**2169**] during liver tx workup, s/p RFA
ablation to kidney mass, s/p [**4-2**] cyberknife tx to lung met on
left, last on [**5-3**]
Adult onset DM, onset [**2160**]
HTN
BPH with normal PSAs
HBV Post-infection
s/p R inguinal hearnia repair [**2161**]
Hx of IVDU, ETOH abuse
Social History:
Occupation: automobile detailer and substance abuse counselor
Drugs: Hx IVDU, drug/substance free x 9 years.
Tobacco: 1ppd
Alcohol: Hx ETOH abuse
Other: Lives alone, no pets. Has a very supportive girlfriend
who is HCV positive. Has a 22 yr old daughter and reports good
relationship with her.
Family History:
Father died from ETOH related complications; mother died from
liver cancer.
? skin cancer
Physical Exam:
98.2, 99, 119/76, 100%
General Appearance: Well nourished, No acute distress,
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), RRR, no heave or JVD
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Bowel sounds present, Distended, Acites
Extremities: Right: trace, Left: 1+
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): , Movement: Purposeful, Tone:
Normal
Pertinent Results:
[**2170-5-8**] CTA CHEST:
IMPRESSION:
1. Large non-occlusive thrombus involving the right and left
main pulmonary arteries extending into the segmental and
subsegmental branches bilaterally.
2. Stable appearance of the left upper lobe mass with interval
improvement in post-obstructive pnuemonia/pneumonitis.
3. Scattered sub-4-mm noncalcified lung nodules as described
above. Attention to these lesions should be paid in followup
scans.
4. Cirrhotic liver with lesion at the dome, best seen on
[**2170-3-7**], CT of the abdomen study.
[**2170-5-8**] CXR:
IMPRESSION: No acute pulmonary process. Stable fiducial markers
as previously noted.
[**2170-5-8**] ECHO:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. There is mild pulmonary artery systolic
hypertension. The pulmonary artery is not well visualized. There
is no pericardial effusion.
IMPRESSION: Mildly dilated and hypokinetic right ventricle. At
least mild pulmonary artery systolic hypertension.
[**2170-5-9**] BLE ULTRASOUND:
IMPRESSION: DVT involving the superficial femoral and popliteal
vein on the left. Clot is also identified in the lesser
saphenous vein on the left. Findings were discussed with Dr.
[**Last Name (STitle) **] upon completion of the study.
[**2170-5-9**] CT HEAD:
IMPRESSION: No hemorrhage and no mass effect.
Brief Hospital Course:
60M with HIV, HCV with cirrhosis/ascites, hx DVT, RCC and HCC
presenting with chest/epigastric pain, found to have large
saddle pulmonary embolus.
1. Submassive pulmonary embolus: The patient's CTA was
consistent with a submassive PE. He was hemodynamically stable.
BLE ultrasounds showed large clot burden. CT head checked given
malignancy and need for anti coagulation--no masses. It was
felt that the patient would need lifelong anticoagulation, but
given the large clot burden and the submassive PE, it was felt
that he would benefit from an IVC filter. This was done by IR.
The patient remained hemodynamically stable. He was started on
a heparin drip in the ICU and was then transferred to the
general medical floor. Maintained on heparin until therapeutic
on coumadin. Patient's anticoagulation to be managed by Dr.
[**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 1226**] office who was contact[**Name (NI) **] and is aware of
need for close monitoring, esp in setting of concurrent
fluconazole therapy. Given extent of VTE, multiple malignancies
and that this is second episode of VTE, patient needs lifelong
anticoagulation.
2. Odynophagia/Dysphagia/Candidal esophagitis: Unclear etiology,
though likely candidal esophagitis given HIV/HCV/malignancy.
Other possibilities include radiation espophagitis vs CMV
esophagitis or contigious spread of malignancy in setting of
thickened appearance on CTA. GI was consulted and they will
evaluate for cause of dysphagia and agreed likely candidal
esophagitis. Empiric three week course of fluconazole initiated
on [**5-8**] and to finish [**5-28**]. Too high risk for endoscopy given PE
and heparin therapy. Patient should have endoscopy within one
month, once stabilized on coumadin regimen, especially given
cirrhosis (? varices) and possibility of spread of malignancy to
esophagus. Symptoms much improved on fluconazole.
3. HIV. The patient gets his care at [**Hospital1 2177**], currently well
controlled on HAART regimen.
CD4 of 100 here. Maintained HAART. Contact[**Name (NI) **] Dr. [**First Name8 (NamePattern2) 1743**]
[**Last Name (NamePattern1) 1226**] office (PCP and ID doctor for Mr. [**Known lastname **]). Bactrim
prophylaxis given.
4. Hepatitis C/Cirrhosis/Ascites: Maintained on home diuretics
(spirinolactone 200 adn lasix 80 with control of ascites -
however, dose reduced given hyponatremia, slight, and slight
increase in Creatinine and dry overall appearence. Patient
should follow up for endoscopy within one month to evaluate for
varices especially given concurrent coumadin therapy (arranged
follow up at [**Hospital1 **] with his GI MD, [**Last Name (un) 14429**])
5.Oncology: RCC/mets to lung/probable HCC: S/p cyberknife
radiation (less likely to cause radiation esophagitis than
traditional XRT). He is not candidate for IL-2 given liver
disease.
6. Diabetes. Continued ISS and standing long-acting per home
regimen
7. BPH: maintained on terasozin.
Medications on Admission:
Spironolactone 200mg daily
lasix 80mg daily
terazosin 5mg daily
Truvada 1 tabl Po QHS
fosamprenavir 700mg [**Hospital1 **]
Discharge Medications:
1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO QHS (once a day (at bedtime)).
4. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16): Dose to be managed by coumadin clinic and Dr.
[**First Name (STitle) **] as arranged.
Disp:*30 Tablet(s)* Refills:*0*
7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for muscle cramping.
Disp:*10 Tablet(s)* Refills:*0*
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. 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:*0*
10. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Thirty Three (33) Units, insulin Subcutaneous QAM insulin.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Eight (38) Units, insulin Subcutaneous at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Massive pulmonary embolus
2. Dysphagia
3. Probable [**Female First Name (un) **] esophagitis
4. Hepatitis C
5. HIV/AIDS
6. Hepatocellular Carcinoma
7. Renal Cell Carcinoma
8. BPH
9. Cirrhosis
10. Ascites
Discharge Condition:
Stable, tolerating PO, therapeutic inr on coumadin
Discharge Instructions:
Follow up as below.
All medications as prescribed. As discussed, you will need to
have lab work monitoring to guide the dose of your coumadin.
You will be on coumadin for the rest of your life given that
this is your second episode of blood clots. We have contact[**Name (NI) **]
your primary care doctor, Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **], and her office
will be managing your coumadin dosing. You will need to get
frequent labs (up to a few times per week initally and then
eventually once or twice a month) to monitor your "INR" level
which shows how effective the coumadin is. Your goal INR is
[**3-4**]. Based on your INR level, your doctor will continue to
adjust your dose of coumadin.
You will continue to take the fluconazole for a total of three
weeks. You were started on [**5-8**] and therefore will continue this
through [**5-28**]. This medication can effect the INR and the
effect of the coumadin and thus you need very close monitoring
in the next few weeks.
Coumadin helps prevent new clots and helps prevent the old clots
from becoming bigger. It thins your blood and makes you more
likely to have bleeding. If you have any signs of bleeding
including blood in your stool you must notify your doctor
immediately.
Other medications can effect the level and make you more likely
to bleed and therefore before any starting new medication, let
your doctors know [**Name5 (PTitle) **] are on coumadin. We have given you
patient information hand-outs about this topic.
Otherwise, take all medications as you were previously before
coming into the hospital; your lasix and spirinolactone were
adjusted down (see med list below).
If you develop chest pain, shortness of breath, fevers, chills,
signs of bleeding, including blood in the stool, contact your
doctor or go to the emergency room immediately.
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **].
As above, you must follow up with her office for anti
coagulation.
Follow up with your liver doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14429**]. You should
be seen within a month and he should perform an upper endoscopy
on you within one month. You are risk of 'esophageal varices'
(enlarged blood vessels in your food pipe) because of your
cirrhosis which can lead to bleeding and the only way to
diagnose/treat these is with endoscopy.
Follow up with your cancer doctors including Dr. [**Last Name (STitle) **].
The following are the appointments we have arranged for you:
[**Hospital 197**] Clinic appointment Appt will be tomorrow a@2:30 pm in
[**Location (un) 47**].
Heart Center of [**Hospital1 **]
Phone: [**Telephone/Fax (1) 6256**]
[**Last Name (NamePattern1) 26916**]., [**Location (un) 47**], [**Numeric Identifier 59599**]
PCP [**Name Initial (PRE) **] ([**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **]) Wednesday [**5-16**] @10:40am at
[**Hospital6 **]. [**Last Name (LF) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 42773**]
Dr. [**Last Name (STitle) 14429**], [**Hospital6 **] - keep your scheduled
appointment for [**6-14**].
ICD9 Codes: 2761, 5715, 4019 | [
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train_29952 | completed | dfaf93f7-e6bb-4262-8f72-ffcfeab58880 | Medical Text: Admission Date: [**2179-2-20**] Discharge Date: [**2179-3-5**]
Date of Birth: [**2102-1-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 22990**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
76 y.o. female with severe COPD x 25+ years, supplemental oxygen
for over a year, DMII, vascular dementia, presenting from home
with respiratory distress.
.
Patient was brought in by EMS after family called due to
increased work of breathing. Patient lives in multi family home
with daughter living in next door house. They report that
patient was recently discharged from rehab on [**2178-2-5**] for
similar complaint, and had been home for about 2 weeks.
Approximately 4 days prior to presentataion, family noted she
was having productive cough with greenish / brown streaked
sputum. They deny any fevers, chills or diaphoresis. On the day
prior to presentation, physical therapy evaluated her at home
and found her oxygen saturation in 80's. Since, she has been
receiving increasing frequency of nebulizer treatments.
.
On date of admission, patient reportedly went to the restroom
where she called for help due to "crushing chest pain" and
difficulty breathing. Family immediately called EMS. During my
evaluation, she denied this chest pain prior to presentation.
.
In the ED, vital signs were initially: 122, 134/116, RR32.
Patient noted to have significant respiratory distress, placed
on NRB with O2 sat in 100's, however initial blood gas
7.19/98/90. Patient given nebulizer treatments, solumedrol,
azithromycin, magnesium and started to CPAP @ 40%, PEEP6, ~20 TV
400's. HR 100, BP 103/53 on nitro initially given for severe
hypertension (200' systolic); however off at time of transfer.
Patient admitted to MICU for further management.
.
REVIEW OF SYSTEMS:
No fevers, chills, weight loss, diaphoresis, headache, visual
changes, sore throat, chest pain, nausea, vomiting, abdominal
pain, constipation, diarrhea, melena, pruritis, easy bruising,
dysuria, skin changes, pruritis.
Past Medical History:
COPD on 2L home O2
DM2
Dementia
HTN
Dyslipidemia
Goiter s/p RAI
R breast nodule
RUL opacity on CT--thought to be scarring from pneumonia, but
ddx includes cancer
Social History:
She continued to smoke one to two packs of cigarettes/day until
[**Month (only) 404**] of this years. She is retired from the post office. She
no longer drinks alcohol but has a remote history of alcohol
abuse.
Family History:
The patient's father died at 71 of complications of diabetes.
She is the oldest of seven siblings of whom only four are
living. There is no history of known dementia in the family.
Physical Exam:
VS: 97.5, 136/79, 102, 28-30, 98% 2L NC, BG 274
GEN: The patient is in some distress with breathing, somewhat
short of breath with long sentences
SKIN: No rashes or skin changes noted
HEENT: JVP = 5-7 cm, neck supple, No lymphadenopathy in
cervical, posterior, or supraclavicular chains noted.
CHEST: Lungs with markedly decreased BS and expiratory wheezing
CARDIAC: Tachycardic, regular rhythm, faint grade I-II systolic
murmur at LLSB.
ABDOMEN: Non-distended, and soft without tenderness
EXTREMITIES: no peripheral edema, warm without cyanosis
NEUROLOGIC: Alert and appropriate. CN II-XII grossly intact. BUE
[**5-26**], and BLE [**5-26**] both proximally and distally. No pronator
drift. Reflexes [**1-23**]+ and symmetric. Downward going toes.
Pertinent Results:
LABS ON ADMISSION:
[**2179-2-20**] 06:43PM BLOOD WBC-9.1 RBC-3.58* Hgb-10.4* Hct-32.3*
MCV-90 MCH-29.0 MCHC-32.1 RDW-13.0 Plt Ct-253
[**2179-2-22**] 04:59AM BLOOD Neuts-75.2* Lymphs-19.3 Monos-5.2 Eos-0.3
Baso-0.1
[**2179-2-20**] 06:43PM BLOOD Plt Ct-253
[**2179-2-20**] 06:43PM BLOOD Fibrino-528*
[**2179-2-20**] 06:43PM BLOOD UreaN-16 Creat-0.8
[**2179-2-20**] 06:43PM BLOOD CK(CPK)-189
[**2179-2-20**] 06:43PM BLOOD Lipase-22
[**2179-2-20**] 06:43PM BLOOD cTropnT-<0.01
[**2179-2-20**] 06:43PM BLOOD CK-MB-5 proBNP-66
[**2179-2-21**] 03:31AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.5
[**2179-2-20**] 07:00PM BLOOD Type-ART O2 Flow-6 pO2-90 pCO2-98*
pH-7.19* calTCO2-39* Base XS-5 Intubat-NOT INTUBA
Comment-NEBULIZER
[**2179-2-20**] 06:44PM BLOOD Glucose-237* Lactate-0.9 Na-134* K-4.5
Cl-86* calHCO3-34*
.
LABS ON DISCHARGE:
[**2179-3-2**] 06:30AM BLOOD WBC-13.6* RBC-3.81* Hgb-10.6* Hct-34.2*
MCV-90 MCH-28.0 MCHC-31.2 RDW-13.9 Plt Ct-289
[**2179-3-1**] 07:55AM BLOOD Neuts-73.6* Lymphs-20.3 Monos-5.5 Eos-0.3
Baso-0.3
[**2179-3-2**] 06:30AM BLOOD Plt Ct-289
[**2179-3-1**] 07:55AM BLOOD Glucose-154* UreaN-26* Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-34* AnGap-9
[**2179-3-1**] 07:55AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2
[**2179-2-26**] 12:13PM BLOOD Type-ART pO2-59* pCO2-51* pH-7.41
calTCO2-33* Base XS-5
.
STUDIES:
.
CHEST X-RAY: ([**2179-2-20**])
PORTABLE UPRIGHT AP VIEW OF THE CHEST: Cardiac silhouette is top
normal in
size. The aorta is tortuous with calcifications present. There
are mild
increased interstitial markings bilaterally, suggestive of mild
interstitial pulmonary edema. Blunting of the costophrenic sulci
bilaterally suggest the presence of small bilateral pleural
effusions. No pneumothorax is visualized. No acute skeletal
abnormalities are visualized.
IMPRESSION: Mild interstitial pulmonary edema with small
bilateral pleural
effusions.
.
CXR ([**2179-2-27**])
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Large lung volumes consistent with COPD. Mild bilateral
apical
thickening. Normal size of the cardiac silhouette, mild
tortuosity of the
thoracic aorta. No focal parenchymal opacities suggesting
pneumonia. Pleural effusions.
.
[**2179-2-22**] CT OF THE CHEST WITH IV CONTRAST:
The heart size is normal. There is no pericardial effusion. Mild
coronary
and aortic calcifications are present. The aorta and main
pulmonary artery
are normal in caliber. Scattered mediastinal and hilar lymph
nodes do not
meet CT criteria for lymphadenopathy.
.
A multinodular goiter is present, with hypoechoic lesions
measuring up to 16 mm. This is unchanged since [**2178-1-26**]. There
is no cervical or axillary lymphadenopathy.
.
The lungs are well aerated to the subsegmental levels. No
pulmonary embolism is seen, although the study is slightly
limited due to respiratory motion-related artifact. There is
diffuse centrilobular emphysema, unchanged since the prior CT
exam from 1/[**2178**]. Within the right upper lobe, there is a 14 x
11 mm enhancing nodule with surrounding ground-glass opacity
(3:21). Previous CT examinations since [**2176**] have shown a
confluent reticular and ground-glass opacity in this area,
compatible with a focal area of scarring. However, the current
study demonstrates a new solid central region, so an underlying
solid mass can no longer be excluded. Within the left upper
lobe, there is a vaguely defined linear region of ground-glass
opacity (3:22), unchanged since prior [**2176**], and compatible with
mild scarring. No other nodules or masses are appreciated. There
is no pleural effusion or pneumothorax.
.
Included views of the upper abdomen demonstrate multiple
gallstones within a normal-appearing gallbladder. The included
views of the liver and spleen are unremarkable.
.
OSSEUS STRUCTURES: Minimal dextroscoliosis is present. Mild
degenerative
changes are present throughout the thoracic spine. Old left
fifth and sixth rib fractures are unchanged. There is no acute
fracture or dislocation. No sclerotic or lytic lesions are
detected.
.
IMPRESSION:
1. No pulmonary embolism detected.
2. Previously seen right upper lobe density now demonstrates a
central solid component. A solid mass cannot be excluded. PET
examination is recommended for further assessment.
3. Persistent vaguely-defined linear area of ground-glass
opacity within the left upper lobe is unchanged and compatible
with mild scarring.
.
[**2179-2-22**] LOWER EXTREMITY ULTRASOUND
FINDINGS: Waveforms of the common femoral veins are symmetric
bilaterally
with appropriate response to Valsalva maneuvers. In both lower
Extremities, the common femoral, proximal greater saphenous,
superficial femoral, and popliteal veins are normal with
appropriate compressibility, wall-to-wall flow and color
analysis and response to augmentation. Wall-to-wall flow is also
present in the posterior tibial and peroneal veins bilaterally.
.
IMPRESSION: No deep venous thrombosis in either lower extremity.
Brief Hospital Course:
Ms [**Known lastname 97068**] is a 77 year old woman with COPD on home O2,
pulmonary hypertension, htn, hyperlipidemia, presenting with
acute COPD exacerbation with unclear trigger, now improved on
BIPAP/steroids/nebs, and noted to have spiculated lung mass
concerning for malignancy.
.
# ACUTE COPD EXACERBATION: At time of admission, patient with
significant respiratory distress. Patient with longstanding
COPD, on supplemental oxygen for the past few years, with single
prior intubation about 1 year ago. Patient does have with very
depressed FEV1 (33% predicted in 2/[**2178**]). No clear preceeding
prodrome, no fevers or chills, however does note sputum color
change. Given degree of acidosis with metabolic compensation,
suspect this has been a slowly progressing decompensation.
Patient was initially placed on BiPAP which she tolerated well,
along with IV solumedrol, q2 prn nebulizers, and Abx. She
received IV solumedrol 125mg and was transitioned to oral
prednisone 60mg PO with a slow taper. She completed 5 days of
azithromycin. Her respiratory virus panel was negative, lower
extremity ultrasound negative and CT negative for PE, although
with incidental finding of interval change in lung mass (see
below). Pulmonary was consulted given slow improvement, and felt
that she would benefit from slow steroid taper along with
chronic low dose PO steroids.
.
# RESPIRATORY ACIDOSIS: At admission very significant acidosis
(pH 7.19/ pCO2 98 /pO2 90) which normalized to her baseline
after BiPAP and above treatment. Suspect large degree of chronic
respiratory acidosis with metabolic compensation, as noted by
chronically elevated bicarbonate.
.
# LUNG MASS: Previously noted on CTA Chest from [**2178-1-26**], however
this admission's CTA demonstrated a 14 x 11 mm right upper lobe
density with central solid component. A solid mass cannot be
excluded. These findings were discussed with patient and family,
and will be pursued with outpatient work-up at next pulmonary
appointment.
.
# SINUS TACHYCARDIA: resolved. DDx included hypovolemia vs.
nebulizer treatment vs. anxiety/COPD flare vs. infection. No
localizing sx of infection and cultures were negative. Improved
with treatment of COPD and slight volume resuscitation.
.
# URINARY TRACT INFECTION: in setting of dysuria and
enterococcus urine culture, patient started on amoxicillin 500
mg [**Hospital1 **]. She has 4 more days of treatment to complete on
discharge.
.
# HYPERLIPIDEMIA: continued pravastatin
.
# DIABETES: Patient was continued glargine and SSI. Discharged
on NPH, and will be titrated based on QID fingersticks at rehab.
.
# VASCULAR DEMENTIA: Per family patient at baseline during
admission.
.
# DEPRESSION: continued Sertraline and Trazodone per outpatient
regimen
.
# Dispo: discharge to rehab, f/u appt with PCP/pulmonary
Medications on Admission:
ALBUTEROL
FLUTICASONE 50 mcg Spray
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/ [**Hospital1 **]
IPRATROPIUM BROMIDE
TIOTROPIUM BROMIDE - 1 capule inhaled once a day
.
VERAPAMIL - 180 mg Tablet Sustained Release daily
LISINOPRIL - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day
PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime
ASPIRIN - 81 mg Tablet
.
SERTRALINE - 25mg Tablet at bedtime
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
ACETAMINOPHEN - (Prescribed by Other Provider) - Dosage
uncertain
CHOLECALCIFEROL (VITAMIN D3) - 400 unit Tablet
DOCUSATE CALCIUM - (Prescribed by Other Provider) - Dosage
uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain
NPH INSULIN HUMAN RECOMB [HUMULIN N] - 22 untis QAM
INSULIN LISPRO [HUMALOG] ?
Discharge Medications:
1. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
11. Prednisone 5 mg Tablet Sig: 40 mg by mouth for 3 days, then
30 mg by mouth for 5 days, then 20 mg by mouth for 5 days, then
10 mg by mouth for 5 days, then 5 mg daily Tablets PO once a day
Tablets PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
13. Humalog 100 unit/mL Solution Sig: as per sliding scale sheet
units Subcutaneous four times a day.
14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day as needed for constipation.
15. Humulin N 100 unit/mL Suspension Sig: Thirty Four (34) units
Subcutaneous once a day.
Disp:*1 vial* Refills:*2*
16. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY:
1. acute exacerbation of chronic COPD
2. right upper lobe mass, concerning for malignancy
.
SECONDARY:
1. diabetes, type II
2. vascular dementia
3. hypertension
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with severe shortness of
breath and a cough productive of greenish/yellow sputum felt to
be from COPD exacerbation. You were placed on BIPAP, given
steroids, and around the clock albuterol nebs to improve your
breathing and oxygenation. You were treated with 5 days of
azithromycin. Your breathing is now back to your baseline on 2
liters of oxygen. You should continue to take oral steroids
according to the following regimen outlined below.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START prednisone 40 mg for 3 days, then go to 30 mg for 5
days, then 20 mg for 5 days, then 10 mg for 5 days, and then 5
mg daily until evaluated by the pulmonary doctors.
- INCREASE NPH insulin to 34 units at bedtime
- START humalog insulin sliding scale as needed for blood sugar
control
- START omeprazole 20 mg daily
- START amoxicillin 500 mg twice a day for 4 days for urinary
tract infection
.
In addition, a lung mass was found on your CT scan. The
pulmonary doctors [**Name5 (PTitle) **] be [**Name5 (PTitle) 62115**] this mass further during
your clinic appointment.
.
Please seek medical attention for any worsening shortness of
breath, difficulty breathing, chest pain, fevers, chills,
abdominal pain, inability to tolerate food, blood in your stool,
or any other concerning symptoms.
Followup Instructions:
We have made an appointment with your primary care doctor, Dr.
[**Last Name (STitle) **], on [**2179-3-10**] at 11:30 AM. Provider [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2179-3-10**] 11:30
.
We have made an appointment with pulmonary clinic with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2179-3-25**] at 9:30 AM. These physicians will also manage
your lung nodule evaluation as well.
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**]
Date/Time:[**2179-3-23**] 10:30
.
Provider PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2179-3-25**] 9:40
Completed by:[**2179-3-5**]
ICD9 Codes: 2762, 5990, 4168, 4019, 2724, 311 | [
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train_25224 | completed | 6d384664-738e-4a3a-b186-4fd6431f85ce | Medical Text: Admission Date: [**2183-1-15**] Discharge Date: [**2183-2-5**]
Date of Birth: [**2119-12-4**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 63-year-old female
patient with a history of atrial fibrillation, hypertension,
diabetes mellitus, severe mitral regurgitation, significant
history of asthma with two recent hospital admissions to [**Hospital6 1760**] for asthmatic exacerbation.
She was also admitted to [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
through [**2182-12-14**] with severe mitral regurgitation and
rapid atrial fibrillation. Heart catheterization was
performed on [**2182-12-16**], which revealed left
ventricular ejection fraction of 68%, single-vessel coronary
artery disease, questionable degree of mitral regurgitation,
and moderate pulmonary hypertension.
The patient subsequently had a retroperitoneal hematoma
requiring blood transfusion after cardiac catheterization.
The patient also had some prerenal azotemia which resolved
during that hospitalization. The patient was subsequently
discharged home with a plan to be readmitted early in [**Month (only) 404**]
for mitral valve replacement with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**].
On the day of admission, [**2183-1-15**], however, the
patient was admitted with chest pain and palpitations which
was of fairly significant onset. The patient had been on
Amiodarone at that time. When EMS responded, she was found
to have a heart rate in the 130s, blood pressure 220
systolic. She was given Aspirin and Nitroglycerin with
relief of her symptoms. She was also treated with
intravenous Lopressor at that time. The patient was admitted
to the Medicine Service.
PAST MEDICAL HISTORY: Type II diabetes mellitus, atrial
fibrillation, hypertension, chronic renal insufficiency with
a baseline creatinine of 1.5-2.0, granulomatous hepatitis,
reactive airway disease with significant history of asthma,
3+ mitral regurgitation, moderate pulmonary hypertension,
status post 6 U blood transfusion for a retroperitoneal
bleed/hematoma status post cardiac catheterization, prerenal
azotemia, hematuria, partial small bowel ileus, history of
monoclonal gammopathy, status post total abdominal
hysterectomy for fibroids, history of hypercholesterolemia.
MEDICATIONS ON ADMISSION: Amiodarone 400 mg p.o. q.d.,
Diltiazem SR 180 mg p.o. b.i.d., Univasc 30 mg p.o. q.d.,
Hydrochlorothiazide 25 mg p.o. q.d., Premarin 0.625 mg p.o.
Q.d., Glyburide 10 mg p.o. b.i.d., Avandia 2 mg p.o. q.d.,
Lipitor 10 mg p.o. q.d., Colace b.i.d., Coumadin 2.5 mg p.o.
q.d., Asthmacort metered dose inhaler, Albuterol metered dose
inhaler, Prednisone 10 mg p.o. q.d.
PHYSICAL EXAMINATION: General: On admission, exam revealed
the patient to be in no acute distress. Neck: Supple. No
jugular venous distention. HEENT: Unremarkable. Lungs:
Clear to auscultation bilaterally. Cardiovascular:
Irregularly, irregular rhythm with a grade 2/6 systolic
murmur. Abdomen: Soft, nontender, nondistended. Positive
bowel sounds. Extremities: Without edema. There were 2+
palpable dorsalis pedis pulses bilaterally. Neurological:
Alert and oriented times three. Nonfocal exam.
LABORATORY DATA: On admission white blood cell count was
21.9; potassium 3.9, creatinine 1.5; the rest of the
admission laboratories were unremarkable; her INR upon
admission was 3.0, and she was on Coumadin.
HOSPITAL COURSE: The patient was admitted to the Medicine
Service. Her Heparin was discontinued with the anticipation
of her needing to go to the Operating Room for her cardiac
surgery, and she was placed on intravenous Heparin drip. An
Endocrinology consult was obtained on the day of admission.
It was their impression that the patient had thyrotoxicosis,
although mild. It was their recommendation to rate control
the patient with beta-blocker as needed and to discontinue
the Amiodarone. The Amiodarone was subsequently discontinued
on [**2183-1-16**].
On [**2183-1-17**], the patient was taken to the Operating
Room by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3876**] where she underwent a mitral
valve replacement with a St. [**Male First Name (un) 1525**] mechanical mitral valve,
#29 mm, as well as left-sided maze procedure. She also had
removal of left atrial appendage.
Postoperatively she was transported from the Operating Room
to the Cardiac Surgery Recovery Unit on epinephrine drip.
She was also on Levophed. Both the epinephrine and Levophed
were weaned off readily. She remained on Insulin drip and
some Nitroglycerin, as well as some Propofol for sedation,
and low-dose Dopamine drip for labile blood pressure.
On postoperative day #1, the patient was seen by the Renal
Medicine Service for increasing creatinine. It was their
recommendation to let the patient stay with a higher blood
pressure for better renal profusion and to follow the
patient's potassium closely.
The patient was weaned from the mechanical ventilator and
extubated on postoperative day #1. On postoperative day #2,
the patient remained in the Intensive Care Unit requiring
Insulin drip still for blood sugar which was not adequately
controlled. She remained on low-dose Dopamine as well.
Amiodarone was resumed on postoperative day #2 due to
continued problems with atrial fibrillation.
On postoperative day #3, the patient was weaned off all
vasoactive drips, and he remained hemodynamically stable and
was transferred out of the Intensive Care Unit to the
Telemetry Floor. Cardiology Electrophysiology Service had
been following the patient, and they recommended to
discontinue the Amiodarone due to her preoperative problems
with thyrotoxicosis. The patient had some intermittent
problems with nausea over the next couple of days. The
patient required pulmonary toilet and bronchodilators,
however, remained essentially stable.
The patient had some difficulties with rapid atrial
tachycardiac arrhythmias, and the Electrophysiology Service
thought that she may at some point require an AB nodal
ablation with permanent pacemaker placement, and Coumadin was
discontinued on [**1-21**] for that reason.
Over the next 24-48 hours, from [**1-23**] to [**1-24**], the
patient had continuing problems with worsening shortness of
breath. On [**1-24**], 6 p.m., the patient was transferred
back to the Intensive Care Unit due to worsening shortness of
breath. She had bibasilar crackles, some hypertension to
150s to 170s systolic. The patient had been on a
non-rebreather mask at that point. Her respiratory rate was
in the 30s.
Over the course of the next three days in the Intensive Care
Unit, she had been started on broad-spectrum antibiotics and
aggressively worked with diuresis and pulmonary toilet;
however, on the morning of [**1-28**], the patient required
reintubation for increasing shortness of breath and fatigue,
at which point she was sedated to tolerate mechanical
ventilation. Subsequent sputum gram stain grew out
gram-negative rods; however, the culture was consistent with
oropharyngeal flora and budding yeast and no definitive
organisms.
A Pulmonary Medicine consultation was obtained on [**2183-1-29**]. It was their thought that the patient may have been
experiencing postpericardiotomy syndrome with questionable
exacerbation of her reactive airway disease. For this
reason, it was their recommendation to increase her steroids.
She had been on her baseline of Prednisone 10 mg per day at
this time. The patient also upon admission to the Intensive
Care Unit had a significant pleural effusion drained of
approximately 700 cc.
On [**2183-1-30**], the patient had significantly improved
from a respiratory standpoint after being on stress dose
steroids for about 48 hours, and she was extubated on [**1-30**], and significant improvement in her pulmonary status was
evident at that time. The patient continued to do well
hemodynamically. She was begun on oral medication and
nutrition which she tolerated well. On [**2183-2-1**], the
patient was transferred out of the Intensive Care Unit to the
Telemetry Floor once again.
Over the next few days, she had been restarted on her
Coumadin. Her INR had increased nicely to the 2.1 to 2.5
range. She remained hemodynamically stable. She began to
progress with some ambulation, however was still extremely
unsteady with her gait and unable to ambulate independently.
The Renal Medicine Service signed off on her care since this
was no longer an active issue.
The patient remained hemodynamically stable and was ready to
be discharged to her rehabilitation facility today, [**2183-2-5**], postoperative day #19.
CONDITION ON DISCHARGE: Temperature 99.1??????, pulse 104, in
atrial fibrillation, respiratory rate 20, blood pressure
145/68, room air oxygen saturation 93%, discharge weight 56
kg, which is actually somewhat below her preoperative weight
of 58.2.
Most recent laboratory values include a prothrombin time of
17.4, with an INR of 2.1, sodium 137, potassium 3.9, chloride
93, CO2 38, BUN 31, creatinine 1.6, fasting glucose 68; white
blood cell count 15.8, which is stable, hematocrit 29.1,
platelet count 293,000.
Physical exam revealed the patient to be neurologically alert
with no apparent deficit. Coronary exam is irregular, rate,
and rhythm. No murmurs or rubs noted. Positive valve click
audible. The patient's lungs are essentially clear to
auscultation bilaterally with the exception of minimal fine
bibasilar crackles. Her abdomen is somewhat distended,
although it is soft with positive bowel sounds. The patient
stated that she had a bowel movement today. She has had
intermittent episodes of complaints of nausea. Her sternum
is stable. Her Steri-Strips are clean, dry, and intact over
her incision. Her extremities are warm and well perfused
with palpable pulses bilaterally. There is some superficial
skin breakdown in the sacral area which is reddened and
healing over.
DISCHARGE MEDICATIONS: Coumadin 4 mg on [**2-5**] and
[**2-6**], the patient is to have a prothrombin time checked
at that point in time to determine ongoing doses, her target
INR should be 3.0-3.5 to anticoagulate her for mechanical
mitral valve, Catapres TTS patch 0.1 mg transdermaly q.week,
Lipitor 10 mg p.o. q.h.s., Levofloxacin 250 mg p.o. q.d. x 5
more days to complete a course for presumed tracheal
bronchitis, Peri-Colace 1 p.o. b.i.d., Protonix 40 mg p.o.
q.d., Enteric Coated Aspirin 325 mg p.o. q.d., Beclovent
metered dose inhaler 2 puffs b.i.d., Albuterol metered dose
inhaler 2 puffs q.4 hours, Premarin 0.625 mg p.o. q.d.,
Amaril 2 mg p.o. q.a.m., Prednisone 10 mg p.o. q.d., Reglan
10 mg p.o. q.8 hours, Diltiazem SR 180 mg p.o. b.i.d.,
Percocet 5/325 1 p.o. q.4 hours p.r.n. pain, sliding regular
Insulin coverage in addition before meals and at bed time for
blood sugar of 150-200 3 U subcue regular Insulin, 201-250 6
U, 251-300 9 U, 301-350 12 U.
FOLLOW-UP: The patient should follow-up with her primary
care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6955**] upon discharge from the
rehabilitation facility to reestablish her plan for diabetes
management, she is on less oral hypoglycemics at this time
because her nutritional status and eating and nausea has not
quite become stable. The patient is also to follow-up with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3876**] upon discharge from the rehabilitation
facility. The patient should follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] from the Electrophysiology Service upon discharge
from the rehabilitation facility. The patient is discharged
in stable condition.
DISCHARGE DIAGNOSIS: Mitral regurgitation status post mitral
valve replacement.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2183-2-5**] 10:38
T: [**2183-2-5**] 10:40
JOB#: [**Job Number 11678**]
ICD9 Codes: 4240, 5185, 4280, 5845, 486 | [
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train_26147 | completed | 4bfce309-f43e-426e-98f1-423fdaaf0433 | Medical Text: Admission Date: [**2128-3-11**] Discharge Date: [**2128-3-17**]
Date of Birth: [**2068-5-1**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Morphine / Codeine / Red Dye / Vioxx / ibuprofen / Bactrim DS /
Glucophage / simvastatin / Crestor / Allopurinol
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Left Knee Pain s/p infection
Major Surgical or Invasive Procedure:
Left Total Hip Conversion Arthroplasty
History of Present Illness:
59 yo female who in [**2127-2-8**] dev left hip pain and was
dx'ed with OA.
In [**2127-9-8**], she has sig worsening of pain in left hip and
sought care at [**Hospital1 **] ED on [**2127-9-20**]. Had IR guided arthrocentesis
c/w septic joint. Taken to OR for washout on [**2127-9-21**] and cx's
showed strep anginosus. Blood cx's taken after initiation of abx
were neg. TTE neg then and she had repeat washout on [**2127-9-24**].
She had imaging c/w osteo. She was seen by ID and she was
treated initially with vanco alone, then ceftriaxone added and
when her strep was [**Last Name (un) 36**] to pen-G, she was switched to Pen G to
complete 6 wks of abx therapy.
On [**2127-10-21**], she was dc'ed to home. She represented 3 days later
with n/v and CP. She was switched from pen G to ceftriaxone
given poss of nause due to pen G.
She was dc'ed on [**2127-10-27**].
She was seen as outpt in [**Hospital **] clinic by Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] on [**2127-11-5**]
and she was nauseated and c/o loose stools. She had completed 6
wks of abx and her inflamm markers were still elevated and she
was still having mobility probs. ID decided to cont treating her
with ceftriaxone 2G iv q 24.
On [**2127-11-21**], she was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from ortho and
he proposed surgery given concern she was failing abx therapy.
on [**2127-12-2**], her ceftriaxone was stopped to max opportunity for
positive cx at time of surgery.
On [**2127-12-16**], she had resection arthroplasty, deep tissue
synovectomy and removal of necrotic tissue with insertion of
vanco/tobra spacer. Post op, she developed hypotension which led
to admission to [**Hospital Unit Name 153**]. She received 5L of LR and 250cc 5% albumin
in PACU.
ICU course - her hct has drifted down to 23. Her blood pressure
has improved but does occasionally drop down which the ICU team
believes is related to her bolus doses of dilaudid.
Past Medical History:
CAD
[**10-11**]: C. cath performed for exertional dyspnea and chest
heaviness with occasional symptoms at rest as well. ETT at
[**Hospital 882**] Hospital was abnormal by report, and echocardiogram
[**2119-9-26**] showed moderate global hypokinesis. She is referred for
right and left heart catheterization for evauation of filling
pressures and coronary anatomy.
[**6-/2127**]: TEE/DCCV cardioversion due to atrial fibrillation.
[**2127-8-5**]: Cavo-tricuspid and coronary sinus RFA for
atrial flutter on [**2127-8-5**]
* DMII
* bilateral knee replacements
* h/o acute renal failure in setting of knee surgery
* osteoarthritis
* Idiopathic Cardiomyopathy diagnosed [**2119**]
* depression
* anemia
* obesity s/p LAGB ([**2126**])
Social History:
SOCIAL HISTORY: Lives in [**Hospital1 6930**] with daughter. Had a difficult
separation from
her husband of 30 [**Name2 (NI) 1686**] about a year ago. Worked as a mammographer
at the [**Hospital1 882**]; recently laid off. Two adult children.
-Tobacco history: never
-ETOH: very rare
-Illicit drugs: none
Family History:
Father died of MI at age 65. Mother had major CVA at 72. Three
sisters with breast cancer, one who recently suffered bilateral
PEs. Mother and 2 sisters with DM.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength
* SILT, NVI distally
* Toes warm
Pertinent Results:
[**2128-3-12**] 11:15AM BLOOD WBC-7.9 RBC-3.35* Hgb-9.2* Hct-28.0*
MCV-84 MCH-27.4 MCHC-32.8 RDW-15.7* Plt Ct-141*
[**2128-3-12**] 06:02AM BLOOD Glucose-144* UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-107 HCO3-24 AnGap-12
[**2128-3-12**] 06:12AM BLOOD Type-ART Temp-36.8 PEEP-5 FiO2-40
pO2-178* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 Intubat-INTUBATED
[**2128-3-11**] 08:02PM BLOOD Glucose-108* Lactate-1.1 Na-142 K-1.5*
Cl-132*
[**2128-3-11**] CXR
Left subclavian PICC line extends to the lower portion of the
SVC. Endotracheal tube tip is approximately 4.5 cm above the
carina. As on the
study of [**2127-12-17**], there are low lung volumes that may be
accentuating the
prominence of the cardiac silhouette. No definite vascular
congestion or
pleural effusion.
[**2128-3-11**] ABD XRAY
There is a left total hip arthroplasty with a proximal cerclage
wire and non-cemented femoral stem. Heterotopic ossification
less likely residual methyl methacrylate is ntoed within the
joint. There is no evidence of hardware failure or
periprosthetic fracture.
[**2128-3-11**] 5:00 pm TISSUE Site: HIP
LEFT HIP #3 Leaking specimen.
GRAM STAIN (Final [**2128-3-11**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2128-3-15**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**10/4201**] [**2128-3-14**]
2PM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
Transfer to the ICU overnight for BP monitoring and 1 L blood
loss. She was extubated and transferred to the floor on POD1.
Excellent work w/ PT
[**Name (NI) **] pain control
Stable Hct
Otherwise, pain was initially controlled with a PCA followed by
a transition to oral pain medications on POD#1. The patient
received lovenox for DVT prophylaxis starting on the morning of
POD#1. The foley was removed on POD#4 and the patient had
difficulty voiding thereafter requiring several straight
catheterizations before she was able to void on her own. The
surgical dressing was changed on POD#2 and the surgical incision
was found to be clean and intact without erythema or abnormal
drainage. The patient was seen daily by physical therapy. Labs
were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
One culture grew Streptococcus Viridans. ID saw and evaluated
her and at this point it was deemed likely a contaminant. She
will return to the IR suite in 2 weeks for repeat Left Hip
Aspiration.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity.
Ms [**Known lastname **] is discharged to home rehab in stable condition.
Medications on Admission:
Colace
Senna
Amiodarone 200 mg qd
Sertraline 100 mg qhs
Dilaudid 2 mg q3 prn
Oxycodone 20 mg q12
APREPITANT 40 mg Capsule take within 3 hours of surgery
Lunesta 1 mg qhs
Lasix 40 mg
INSULIN ASPART sliding scale
INSULIN DETEMIR [LEVEMIR] 18 units qhs
Lisinopril 10 mg qd
Metoprolol Succinate 100 mg qd
Zolpidem qhs
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for Pain.
Disp:*120 Tablet(s)* Refills:*0*
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
3. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 3 weeks.
Disp:*21 syringe* Refills:*0*
4. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. oxycodone 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for
3 weeks: to begin once Lovenox has stopped.
Disp:*42 Tablet(s)* Refills:*0*
13. Levemir 100 unit/mL Solution Sig: Eighteen (18) units
Subcutaneous at bedtime.
14. insulin regular human 100 unit/mL Solution Sig: sliding
scale units Injection qac qhs.
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Left hip infection s/p resection now w/ replantation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: 50% Weight bearing as tolerated on the operative
extremity. Anterior and Posterior precautions. Knee immobilizer
on at all times. No strenuous exercise or heavy lifting until
follow up appointment. Mobilize frequently
Physical Therapy:
Activity: Activity: Activity as tolerated
Left lower extremity: Partial weight bearing
Knee immobilizer: At all times
50% weight bearing. Abductor pillow to be removed once Pt
extubated and stable and replaced with Knee immobilizer.
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: on AM of POD 2 by HO, then daily by RN; please
overwrap any dressing bleedthrough with ABDs and ACE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2128-4-9**] 12:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2128-7-19**] 2:00
ICD9 Codes: 4254, 2851, 412, 311, 2724 | [
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train_24827 | completed | b17c20ee-c8ac-4a52-aaf4-9386bfe83e84 | Medical Text: Admission Date: [**2145-5-6**] Discharge Date: [**2145-5-15**]
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old female
with a history of gastritis, hypertension and
hypercholesterolemia who was admitted to the [**Hospital Unit Name 196**] Service on
[**2145-5-6**] for the complaint of progressive chest pain.
The patient described a two to three month history of
progressive shortness of breath and substernal chest pain.
The patient stated that the chest pain originally occurred at
rest and reported that her episodes had become more severe
over the ensuing time. The patient's episodes were
characterized by pain radiating to both arms that would
occasionally wake her up at night and lasted approximately 30
minutes in duration. The patient was reportedly evaluated by
her primary care physician and was presumptively diagnosed
with gastritis; an esophagogastroduodenoscopy conducted on
[**2145-4-13**] demonstrated mild gastritis which resulted in
outpatient treatment with Maalox and Protonix prn. The
patient continued to demonstrate worsening symptoms,
resulting eventually in a MIBI stress test on [**5-5**] which
demonstrated severe lateral wall reversible defects. The
patient was subsequently advised to come immediately to the
Emergency Department at [**Hospital6 256**],
where she was noted to have ST depressions in leads 2, AVF,
V5 and 6 and an old T wave inversion in leads 1 and AVL. The
patient was subsequently started on heparin and nitroglycerin
drip which brought immediate relief of her chest pain
symptoms and she was subsequently admitted to the Medicine
Service on [**5-6**] for further evaluation and treatment.
PAST MEDICAL HISTORY: Hypertension; hypercholesterolemia;
colon cancer; status post colectomy; breast cancer;
peripheral vascular disease; gastritis; status post right
total hip repair; status post thyronodular excision.
HOME MEDICATIONS: Sinemet; Levo Carbidopa; Lipitor;
Atenolol; Norvasc; Hydrochlorothiazide; Protonix; Benicar;
Timolol; Maalox; Tylenol; Multivitamin; calcium; fish oil.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Widowed and lives in [**Location 1439**] [**State 350**]
with daughter, formerly worked as a secretary and is now
retired. No smoking and no alcohol history.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2145-5-6**]. Initial inpatient therapy
included Aspirin, statins, heparin, and Nitroglycerin drip,
on which regimen the patient was noted to have significant
relief of her chest pain. Cardiac catheterization performed
on [**2145-5-7**] demonstrated three vessel coronary artery
disease, moderate mitral regurgitation, moderate diastolic
ventricular dysfunction, and mild systolic ventricular
dysfunction. A 30 cc intra-aortic balloon pump was inserted
without complication through the course of the procedure.
The patient's ejection fraction was noted to be approximately
50%. Following catheterization, the patient was admitted to
the Cardiac Care Unit for further evaluation and management.
The patient was subsequently evaluated by the Cardiothoracic
Surgery Service and scheduled for urgent coronary artery
bypass graft on [**2145-5-10**]. On [**5-10**], the patient
underwent an off pump coronary artery bypass graft times one
with anastomosis of the left internal mammary artery to the
left anterior descending with a plan for postoperative
stenting. The patient tolerated the procedure well without
complications. The patient's pericardium was left open;
lines placed including an arterial line, Swan-Ganz catheter,
and intra-aortic balloon pump; wires placed included
ventricular pacer wires; two slits including mediastinal,
right and left pleural tubes. On transfer to the
Cardiothoracic Surgery Recovery Unit, the patient
demonstrated a mean arterial pressure of 92, central venous
pressure of 0, PAD of 8 and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1052**] of 18. The patient
demonstrated a heartrate of 84 in normal sinus rhythm. Drips
on transfer included Neo 0.7 and Propofol at 10. In the
Cardiothoracic Surgery Recovery Unit, the patient progressed
well clinically and was successfully extubated on
postoperative day #1, [**5-11**]. The patient was returned to
the Catheterization Laboratory on postoperative day #1, where
stents were placed both to the circumflex and ramus. On
postoperative day #2, the patient was cleared for transfer to
the floor, at which point her IABP was removed and her cordis
was changed to a triple lumen catheter without complication.
The patient was subsequently admitted to the Cardiothoracic
Service on direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. Postoperatively
the patient progressed well clinically. Physical therapy
evaluation recommended the patient for [**Hospital 5735**]
rehabilitation following discharge, after which point the
patient was successfully screened for placement. On
postoperative day #4, the patient's chest tubes were removed
without complication; subsequent chest x-ray demonstrated no
evidence of pneuomothorax. The patient was successfully
advanced to a regular p.o. diet and was noted to have
adequate pain control via oral pain medications. On
postoperative day #5, [**2145-5-15**], the patient was cleared
for discharge to a rehabilitation facility with instructions
for follow up.
CONDITION ON DISCHARGE: The patient is to be discharged to
an extended care facility with instructions for follow up.
STATUS ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. q. 12 hours
2. Pantoprazole 40 mg p.o. q. 12 hours
3. Potassium chloride 20 mEq p.o. q. 12 hours
4. Docusate sodium 100 mg p.o. b.i.d.
5. Aspirin 325 mg p.o. q.d.
6. Plavix 75 mg p.o. q.d.
7. Carbidopa Levodopa 20/100 mg tablets one tablet p.o.
t.i.d.
8. Carbidopa levodopa 25/100 mg tablets one tablet p.o.
b.i.d.
9. Atorvastatin 20 mg p.o. q. day
10. Timolol Maleate 0.25% eye drops one drop ophthalmic
q.h.s.
11. Losartan 25 mg p.o. q.d.
12. Lopressor 50 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS: The patient is to maintain her
incisions clean and dry at all times. The patient may shower
but she should pat dry incisions afterwards; no bathing or
swimming. The patient may resume a regular diet. The
patient has been advised to limit physical activities, no
heavy exertion, no driving while taking prescription pain
medications. Follow up with primary care provider within one
to two weeks following discharge. Follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 1537**] within four weeks of discharge. The patient has been
advised to call to schedule both appointments.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2145-5-15**] 13:25
T: [**2145-5-15**] 15:41
JOB#: [**Job Number 5736**]
ICD9 Codes: 4280, 4240, 4019 | [
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train_29364 | completed | 3bcdf4b6-2aa8-47e5-902c-99daf8cd3b06 | Medical Text: Admission Date: [**2122-12-22**] Discharge Date: [**2122-12-31**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old
female with a past medical history of multiple myeloma status
post treatment with chemotherapy and radiotherapy, last
treated approximately one year prior to admission, who
presented with shortness of breath and fever lasting
the patient was doing well until approximately 4:30 p.m. on
the afternoon of admission when she returned home from work
and noticed that her mother felt "clammy," had difficulty
breathing, and was febrile to 101.5??????. She reported that her
mother has had a dry cough for several days that worsened on
the day of admission. The cough has never been productive of
sputum. The patient was brought to the Emergency Room for
cough.
She denied chills, night sweats, abdominal pain, urinary
tract changes, swelling of lower extremities, musculoskeletal
aches and pain, headaches, constipation, diarrhea, nausea,
and vomiting. She was hypotensive at 70/40 in the Emergency
Room and was started on Dopamine drip.
PAST MEDICAL HISTORY: 1. Multiple myeloma. 2. Type 2
diabetes. 3. Pneumonia 6-8 weeks prior to admission.
MEDICATIONS ON ADMISSION: Micronase, ................,
Decadron q.month.
SOCIAL HISTORY: The patient lives with her daughter. [**Name (NI) **]
smoking or alcohol use. She is ambulatory.
FAMILY HISTORY: Father and brother had history of cancer.
ALLERGIES: MORPHINE SULFATE, CODEINE, OXYCONTIN.
PHYSICAL EXAMINATION: Vital signs: Temperature 103.2??????,
88/30, respirations 39, heart rate 94, oxygen saturation 97%
on 75% non-rebreather. General: She was a tachypneic,
elderly white female sitting up in bed in obvious respiratory
distress. HEENT: Normocephalic, atraumatic. Pupils equal,
round and reactive to light. Extraocular movements intact.
Dry mucous membranes. Pulmonary: Diffuse rhonchus breath
sounds. Expiratory wheezing throughout. Cardiovascular:
Positive tachycardia. Normal S1 and S2. No murmurs, rubs or
gallops. Abdomen: Soft, nontender, nondistended. No
rebound or guarding. Soft bowel sounds times four.
Extremities: There were 2+ pulses in lower extremities. No
[**Last Name (un) 5813**]. No swelling. Right knee with bandage.
Neurological: She was grossly intact.
LABORATORY DATA: White count 2.5, hematocrit 27.7, platelet
count 242; sodium 123, potassium 5.9, chloride 98, bicarb 21,
BUN 18, creatinine 0.7, glucose 332; ABG with a pH of 7.37,
carbon dioxide 36, oxygen 151; CK 92, troponin 0.7.
Chest x-ray showed right middle lobe infiltrate.
HOSPITAL COURSE: She was admitted to the MICU Green Team.
After a long, complicated hospital course involving
intubation and unsuccessful trials of extubation, THE PATIENT
WAS MADE COMFORT MEASURES ONLY. She expired on [**2122-12-31**].
CONDITION ON DISCHARGE: Deceased. No postmorbid examination
was obtained.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2123-2-17**] 15:26
T: [**2123-2-17**] 15:51
JOB#: [**Job Number 20533**]
ICD9 Codes: 486, 0389, 4280, 2761 | [
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train_29383 | completed | 59e6a68d-bcc0-4b1f-88d8-742b86da6a40 | Medical Text: Admission Date: [**2178-10-16**] Discharge Date:
Service:
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: The patient had been
experiencing intermittent back pain over the past week who
has a well known history of osteoarthritis of the spine. He
was given Percocet for pain control without improvement in
his symptomatology. He was seen in the Emergency Room on
[**2178-10-16**] and at that time because of increasing pain and drop
in his hematocrit from 30.0 to 20.6. The patient denies any
chest pain or short of breath. He is admitted for urgent
repair of a ruptured abdominal aortic aneurysm 8 cm in size.
PAST MEDICAL HISTORY: Osteoarthritis, T-spine compression
fracture.
PAST SURGICAL HISTORY: Right inguinal hernia repair.
Vertebral steroid injections.
The patient is a previous smoker.
MEDICATIONS:
1. Zantac.
2. Fosamax.
3. Iron.
4. Percocet.
The patient is not allergic to any foods or drugs. Does have
a history of asbestos exposure.
PHYSICAL EXAMINATION: Shows vital signs 96.1, 142/86, 90,
18, room air sat was 96% Head, eyes, ears, nose and throat
exam is unremarkable. There are no carotid bruits. Lungs
are clear to auscultation. Heart is regular rate and rhythm.
Abdomen is distended with bowel sounds, is nontender. There
is no bruits. Extremities have palpable femoral pulses
bilaterally without distal dorsalis pedis bilaterally. The
rectal exam was guaiac negative.
LABS: Hematocrit of 20.6 with a white count of 16.5, BUN 42,
creatinine 1.7. Potassium 4.7. Urinalysis was positive for
nitrates.
Chest x-ray showed bilateral pleural effusions with pleural
plaques, the right greater than the left.
Electrocardiogram was without acute changes. Normal sinus
rhythm.
The patient was taken to the operating room and underwent
abdominal aortic aneurysm repair. He was then transfused 12
units of packed red blood cells and also received 5 units of
FFP and two units of platelets intraoperatively. He remained
intubated, was transferred to the SICU for continued
monitoring and care. His SICU course was prolonged and
complicated by respiratory failure. He had multiple blood
cultures drawn and urine cultures obtained because of failure
to wean. His sputum cultures were on [**10-21**] negative. His
urine culture on [**10-18**] and [**10-16**] were negative. He underwent
a bronchoscopy on [**10-23**] with Endotracheal tube change at that
time. There were no blockages seen, vocal cords were normal
and there was mild bronchial edema on the mucosa,
endotracheal bronchial tree. The right IJ cortise was
converted to a central line on [**10-25**] and required left
subclavian line placement later that day. The patient
remained intubated, chest x-ray remained unremarkable except
for the bilateral pleural effusions and some basilar
atelectasis.
The patient was finally extubated on [**2178-10-28**]. Physical
therapy was requested for evaluation. During this period in
SICU the patient required TPN and tube feed support.
On [**2178-10-30**] the patient passed flatus and had a bowel
movement. He was then at that time transferred to MICU for
continued monitoring and care.
On [**11-5**] the left subclavian line was changed to left IJ. He
was begun on p.o.'s and diet advanced as tolerated. The TPN
and tube feeds were discontinued after caloric intake was
evaluated.
On [**2178-11-8**] the patient became tachypneic and tachycardiac.
Electrocardiogram was without acute ischemic changes. A
chest x-ray was unchanged. The chest CT was negative for
pulmonary embolism. Abdominal CT showed distended
gallbladder. His liver function tests were elevated with an
ALT of 94, AST 81, Alk phos 293, total bili 6.9, Lipase 73,
amylase 106, lactate was 1.8, blood gases 7.38, 31, 99 and 13
with an elevated white count of 33.0 with a T-max of 102.6.
The patient required re-intubation and transfer to the SICU.
Gastrointestinal was consulted. An ultrasound of the
gallbladder was obtained and needle aspirate was done. The
patient was empirically begun on Unasyn. The cultures of the
blood, urine, sputum and gallbladder were no growth. The
Infectious Disease was consulted at this time. He was
empirically started on Unasyn, Vancomycin and Flagyl. CK and
Troponin levels were obtained and they were flat.
On [**11-10**] the patient was extubated without incident and the
right subclavian line was changed. Cultures were sent to the
line, at this point of the dictation are no growth but not
finalized. Vancomycin was discontinued. Oxacillin was begun
on [**2178-11-11**] 2 grams q 6 hours for suspected line sepsis. The
Nasogastric tube was removed. His diet was advanced as
tolerated on [**2178-11-12**]. PICC line was placed and the central
line was discontinued. He received two units of packed cells
for hematocrit. Oxacillin was started for the enterococcus
which was 10,000 to 100,000 organisms in his urine culture
and sensitivity on [**2178-11-8**].
The transfusion was for a hematocrit of 26.7, he received two
units. His post transfusion crit was 33.3.
The patient continued to do well. Physical therapy continued
to work with the patient. Recommended rehabilitation and
case management was requested to screen the patient
appropriate facilities.
At the time of discharge the patient's wounds were clean, dry
and intact. He was medically stable.
DISCHARGE MEDICATION:
1. Albuterol multidose inhaler puffs two q 4 hours.
2. Insulin sliding scale, glucose of less than 60 no
insulin, glucoses 131 to 151 one unit, 151 to 200
two units, 201 to 250 4 units, 251 to 300 6 units,
301 to 350 8 units, 351 to 400 10 units, greater than
400 12 units and call.
3. Heparin subcutaneously b.i.d.
4. Boost with meals.
5. Vioxx 25 mg q day.
6. Lasix 20 mg q day.
7. Lopressor 37.5 mg b.i.d.
8. Albuterol, Atrovent nebulizer treatments q 4 hours p.r.n.
9. Oxacillin 2 grams intravenous q 4 hours for a total of
two weeks.
FOLLOW-UP: Patient should be seen by Dr. [**Last Name (STitle) **] in two
weeks post discharge.
DISCHARGE DIAGNOSIS:
1. Ruptured abdominal aortic aneurysm with repair.
2. Metabolic acidosis, etiology undetermined, corrected.
3. Respiratory failure requiring prolonged intubation,
extubated, stable.
4. Blood loss anemia, transfused, corrected.
5. Enterococcus urinary tract infection treated.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2178-11-15**] 16:59
T: [**2178-11-15**] 16:57
JOB#: [**Job Number 6224**]
ICD9 Codes: 2762, 2851, 5990 | [
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train_31018 | completed | 18f94be6-b517-494a-8e37-795135b21045 | Medical Text: Admission Date: [**2137-5-25**] Discharge Date: [**2137-6-1**]
Date of Birth: [**2056-2-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
band-like abdominal pain across epigastrum
Major Surgical or Invasive Procedure:
percutaneous cholecystectomy tube [**2137-5-28**]
previous: Ascending Aortic Aneurysm s/p replacement Atrial
fibrillation s/p MAZE and LAA ligation [**2137-05-25**]
Past Medical History:
Aortic, mitral, and tricuspid valve regurgitation
Dyslipidemia
Hypertension
Diverticulosis
Cataract Surgery
Bladder Suspension
cholecystitis
Social History:
Lives with: Son
[**Name (NI) 1139**]: [**Name2 (NI) 4084**]
ETOH: Rare
Family History:
Non contributory
Physical Exam:
Pulse: 56 Resp: 18 O2 sat: 96% RA
B/P Right: 99/69 Left:
Height: Weight:65.7 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]. Healing sternal incision, no
erythema. sternum stable.
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft, slightly distended and tender to light touch over
epigastrum, + rebound tenderness in the area as well. Bowel
sounds present in all 4 quadrants.
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] trace edema bilat
Neuro: Grossly intact
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: 2+ Left: 2+
Pertinent Results:
[**2137-5-25**]
Gall Bladder u/s:
IMPRESSION:
Slightly distended gallbladder and wall edema but no evidence of
stones.
Findings are equivocal for acute cholecystitis, however
acalculous
cholecystitis and further workup with HIDA scan is recommended
if clinically
indicated.
[**2137-5-28**]
IMPRESSION: Thick-walled gallbladder with a son[**Name (NI) 493**] [**Name2 (NI) 515**]
sign
consistent with acute cholecystitis. Planned percutaneous
cholecystostomy not performed in view of the patient's airway,
the procedure has been re-scheduled for tomorrow under
anaesthesia care.
[**2137-6-1**] 05:40AM BLOOD WBC-5.6 RBC-3.18* Hgb-10.2* Hct-28.5*
MCV-90 MCH-32.0 MCHC-35.7* RDW-17.1* Plt Ct-156
[**2137-6-1**] 05:40AM BLOOD PT-26.6* INR(PT)-2.5*
[**2137-5-31**] 04:25AM BLOOD PT-21.3* INR(PT)-2.0*
[**2137-6-1**] 05:40AM BLOOD UreaN-15 Creat-0.9 Na-132* K-3.0* Cl-98
[**2137-5-27**] 03:39AM BLOOD ALT-21 AST-19 LD(LDH)-187 AlkPhos-70
Amylase-18 TotBili-0.4
[**2137-5-27**] 03:39AM BLOOD Lipase-20
[**2137-6-1**] 05:40AM BLOOD Mg-1.8
Brief Hospital Course:
Mrs. [**Last Name (STitle) 105219**] was admitted via the emergency room w/ 2 day history
of increasing upper quadrant abdominal pain and lack of
appetite. A RUQ ultrasound revealed acute cholecystitis.
General surgery was consulted and given her recent replacement
of ascending aorta and hemiarch/MAZE on [**2137-4-25**] a percutaneous
cholecysteostomy tube was placed. Coumadin (for afib) was held
and her INR drifted down prior to the procedure. She was
started on IV cipro and flagyl, then abx DCed per general
surgery.Her coumadin was resumed on [**2137-5-29**]. Her diet was
advanced to regular heart healthy which she is slowly
tolerating. On HD # 7 she was cleared for discharge to [**Hospital 100**]
Rehab. Target INR 2.0-2.5 for A Fib. She is to f/u with Dr. [**Last Name (STitle) 853**]
in 2 weeks( please call for appt). Na+ on day of discharge 132.
Will be monitored at rehab.
Medications on Admission:
docusate sodium 100 mg PO BID, aspirin 81 mg DAILY, metoprolol
tartrate 25 mg PO BID, amiodarone 200 mg twice a day, Decrease
to 200 mg daily in 1 week, warfarin 1 mg Tablet PO once a day:
Please titrate for goal INR of [**2-27**].5 for atrial fibrillation,
acetaminophen 325 mg Two (2) Tablet PO Q6H
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): right
neck extending toward right shoulder along sternocleomastoid
muscle track
.
2. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
dose today [**6-1**] 1 mg only then all further daily dosing per rehab
provider;target INR 2.0-2.5 for A Fib.
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): please monitor weights and BUN/creatinine/K+ / Sodium
daily .
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day: hold for K+
> 4.5.
8. Outpatient Lab Work
K+/ Na+ daily until stabilized on lasix dosing
9. Outpatient Lab Work
please check potassium and magnesium levels Sunday [**6-2**] with
PT/INR
10. fluid restriction
please fluid restrict and monitor Na+ daily until completely
normalized
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Ascending Aortic Aneurysm s/p replacement Atrial fibrillation
s/p MAZE and LAA ligation [**2137-05-25**]
Cholecystitis
Past medical history:
Dyslipidemia
Hypertension
Diverticulosis
Past Surgical History: Cataract Surgery, Bladder Suspension
Discharge Condition:
Discharge Condition: Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- none
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
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) 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
5) No lifting more than 10 pounds for 10 weeks
6) 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**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0-2.5
First INR draw Sunday [**6-2**] and then as clinically indicated.
Coumadin follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 30837**] Please arrange
prior to discharge from rehab.
**You have a percutaneous cholecystostomy tube in place. If you
should have any problems, please call Dr. [**Last Name (STitle) 853**] ( General
[**Doctor First Name **].).Please call for f/u appt in 2 weeks.
Followup Instructions:
You are scheduled for the following appointments
Dr. [**Last Name (STitle) 853**] (general surgery for biliary drainage tube)
[**Telephone/Fax (1) 600**]
You have a percutaneous cholecystostomy tube in place. If you
should have any problems, please call Dr. [**Last Name (STitle) 853**] ( General
[**Doctor First Name **].).Please call for f/u appt in 2 weeks.
Please call to schedule appointments with your
Cardiologist: Dr. [**Last Name (STitle) 5858**] in 3 weeks - [**Telephone/Fax (1) 4105**]
Primary Care Dr [**Last Name (STitle) **] in [**2-28**] weeks [**Telephone/Fax (1) 30837**]
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0-2.5
First INR draw Sunday [**6-2**] and then as clinically indicated.
**Coumadin follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 30837**]. Please arrange
prior to discharge from rehab.
**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:[**2137-6-1**]
ICD9 Codes: 4019, 2724 | [
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train_31417 | completed | 195615cc-fda8-4b18-8153-cbde3ec9b1eb | Medical Text: Admission Date: [**2136-3-18**] Discharge Date: [**2136-3-19**]
Date of Birth: [**2078-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CVL insertion x2
Intubation
Pressors
Arterial line placement
History of Present Illness:
Patient is a 57 y/o male with prostate CA, metastatic melanoma
s/p chemo [**2136-3-14**] (dacarbazine), HTN and anxiety who presented
from home complaining of increased SOB over the past 2 days.
Patient unable to give history currently so history obtained
from chart. Per notes patient was unable to ambulate due to his
breathing and also reported decreased PO since his chemo. Also
has had decreased UOP and no BM. Per ED nursing notes the
patient was also complaining of RUQ pain. He called his outpt.
oncologist with these complaints and was referred to the ED.
.
In the ED the patient was noted to be cool and cyanotic but was
able to answer questions. Initial VS showed T 97.8 rectally, HR
69, BP 105/54, RR 28 and O2 sat was unobtainable. EKG showed
afib, FSBG 76, received [**12-28**] amp D50. IJ CVL attempted on both
sides unsuccessfully (unable to pass wire). ABG 7.17/17/104/7
with lactate 11.2. Started on levophed for BP 85/49. Received
vanco 1gm and cefipime 2gm. Patient was intubated and given a
total of 6L IVF. Foley placed with 20cc UOP. CT torso showed no
PE, extensive mets to liver (known), b/l atelectasis and
persistent pancreatic ductal dilatation and calcification. INR
noted to be 14.1 and pt. was given vit K 5mg and 2 units FFP. A
right fem line was placed and the patient was admitted to MICU 7
for further treatment. Multiple attempts were made to reach the
patient's brother without response.
.
On arrival to the ICU the patient was unresponsive, cool and
cyanotic. A RIJ CVL was placed and repeat ABG 6.82/47/114.
Past Medical History:
metastatic melanoma with PET uptake in liver and bones
anxiety/panic attacks
hypertension
atrial fibrillation
prostate cancer diagnosed [**12-2**]
splenectomy - ?alcohol related (per patient)
Social History:
No smoking. Drinking history: 1 case of beers a day for 35
years, has quit entirely 3 years ago. He drank to calm his
anxiety, but since starting oxazepam has not needed alcohol.
Denies illicit drug use. Lives alone in the [**Hospital1 778**] area. For a
living he cooks at a North Station facility that trains handicap
individuals. Has not worked since the melanoma diagnosis.
Family History:
Fa w/brain ca died in his 50s. Mother died of MI at 75. Sister
overdosed on heroin at 38. Brother healthy, 53yo.
Physical Exam:
VS: BP 108/42 HR 68 RR 12 O2 sat unatainable
Gen: intubated, sedated
Skin: mottled
HEENT: ETT, OG tube, pupils pinpoint, sluggish
NECK: Supple, no JVD
CV: irreg irreg, NL rate. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**]
Lungs: CTA anteriorly
Abdomen: soft, large well-healed scar across left side of
abdomen, ND, +BS
Ext: 2+ pedal edema, cool, cyanotic, pulses dopplerable
Neuro: sedated, absent corneal reflex
Pertinent Results:
[**2136-3-18**] 01:13PM BLOOD WBC-20.6* RBC-4.66 Hgb-14.4 Hct-44.4
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.0 Plt Ct-261
[**2136-3-18**] 07:34PM BLOOD WBC-16.9* RBC-3.61* Hgb-11.2*# Hct-35.9*
MCV-99* MCH-30.9 MCHC-31.1 RDW-14.7 Plt Ct-225
[**2136-3-18**] 11:50PM BLOOD WBC-16.3* RBC-3.38* Hgb-10.5* Hct-34.0*
MCV-101* MCH-30.9 MCHC-30.8* RDW-14.7 Plt Ct-214
[**2136-3-18**] 01:13PM BLOOD PT-104.8* PTT-150* INR(PT)-14.1*
[**2136-3-18**] 07:34PM BLOOD PT-48.9* PTT-150* INR(PT)-5.5*
[**2136-3-18**] 11:50PM BLOOD PT-36.3* PTT-150* INR(PT)-3.9*
[**2136-3-18**] 01:13PM BLOOD Glucose-66* UreaN-77* Creat-6.2*# Na-123*
K-5.7* Cl-83* HCO3-6* AnGap-40*
[**2136-3-18**] 07:34PM BLOOD Glucose-150* UreaN-68* Creat-5.5* Na-122*
K-5.7* Cl-95* HCO3-8* AnGap-25*
[**2136-3-18**] 11:50PM BLOOD Glucose-102 UreaN-68* Creat-5.6* Na-126*
K-6.3* Cl-91* HCO3-LESS THAN
[**2136-3-18**] 01:13PM BLOOD ALT-108* AST-623* AlkPhos-319*
TotBili-3.2*
[**2136-3-18**] 01:13PM BLOOD CK-MB-40* cTropnT-<0.01
[**2136-3-18**] 11:50PM BLOOD CK-MB-61* MB Indx-2.3 cTropnT-<0.01
[**2136-3-18**] 01:13PM BLOOD Albumin-2.8* Calcium-8.0* Phos-10.7*#
Mg-2.1
[**2136-3-18**] 07:34PM BLOOD Calcium-6.3* Phos-10.8* Mg-2.1
[**2136-3-18**] 11:50PM BLOOD Calcium-6.8* Phos-12.1* Mg-2.3
[**2136-3-18**] 07:34PM BLOOD Digoxin-2.5*
[**2136-3-18**] 01:13PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-15.9
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2136-3-18**] 02:31PM BLOOD pO2-104 pCO2-17* pH-7.17* calTCO2-7* Base
XS--20
[**2136-3-18**] 07:42PM BLOOD Type-[**Last Name (un) **] Rates-/12 Tidal V-550 PEEP-5
FiO2-100 pO2-70* pCO2-56* pH-6.79* calTCO2-10* Base XS--29
AADO2-605 REQ O2-96 Intubat-INTUBATED Vent-CONTROLLED
[**2136-3-18**] 08:00PM BLOOD Type-ART pO2-114* pCO2-47* pH-6.82*
calTCO2-9* Base XS--28
[**2136-3-18**] 09:36PM BLOOD Type-ART pO2-108* pCO2-36 pH-6.92*
calTCO2-8* Base XS--26
[**2136-3-18**] 11:06PM BLOOD Type-ART Rates-30/ pO2-93 pCO2-28*
pH-6.88* calTCO2-6* Base XS--29 -ASSIST/CON Intubat-INTUBATED
[**2136-3-18**] 11:51PM BLOOD Type-ART pH-6.85*
[**2136-3-19**] 01:28AM BLOOD Type-ART pO2-89 pCO2-24* pH-6.90*
calTCO2-5* Base XS--29
[**2136-3-18**] 02:07PM BLOOD Lactate-11.2* K-4.8
[**2136-3-18**] 02:31PM BLOOD Glucose-113* Lactate-10.9* K-4.4
[**2136-3-18**] 05:29PM BLOOD Glucose-106* Lactate-10.3* K-5.1
[**2136-3-18**] 07:42PM BLOOD Lactate-11.0*
[**2136-3-18**] 09:36PM BLOOD Lactate-11.9*
.
Studies:.
CXR [**3-18**]: A single portable upright radiograph is available for
review obtained at 2:10 p.m. There is cardiomegaly, without
interstitial opacities to suggest acute pulmonary edema. New
bibasilar opacities are most consistent with
effusions/atelectasis; however, underlying consolidation cannot
be completely excluded. There is no evidence of
pneumoperitoneum.
.
CTA chest/abd:
1. No evidence of pulmonary embolism.
2. Extensive metastatic disease to the liver.
3. Soft tissue and induration in the left axilla with enlarged
lymph nodes, consistent with known metastatic disease.
4. Persistent pancreatic ductal dilatation and calcification.
5. No definite osseous lesions to correspond to multiple foci of
metastatic disease on recent FDG-PET of the torso.
.
EKG: afib, rate 67, poor r-wave progression, no significant ST
changes
Brief Hospital Course:
A/P: 57 y/o M with PMH metastatic melanoma, prostate CA, HTN and
anxiety who presents with profound acidosis, respiratory
failure, acute renal failure, hepatic failure and septic shock,
intubated and on pressors.
.
# Shock: presumed sepsis given elevated WBC, hypothermia,
elevated lactate. Had retrocardiac opacity on CXR concerning for
PNA, also dirty UA concerning for GU source. Not neutropenic but
had recent chemo on [**3-14**] so likely immunosuppressed, also s/p
splenectomy. DDx also included cardiogenic shock, however EKG
unchanged and first set of enzymes neg. No e/o PE on CTA. With
h/o [**Month (only) **]. PO and diuretics, hypovolemia also contributing.
Lactate elevated, however in setting of liver mets and liver
failure. Patient was given aggressive IVF resuscitation to
maintain CVP>13. Received 6L in ED and additional 2L on arrival
to ICU. A second CVL (RIJ) was placed and CVP measured 16-18
indicating adequate fluid resuscitation. He was continued on
levophed which was titrated up to maximum dose. The patient
only made 5cc of urine in the ICU and renal was consulted given
worsening acidosis and anuria. Given his hemodynamic
instability and coagulopathy they felt that inserting an HD
catheter for dialysis was too unsafe and risky in this patient.
He was given 2 amps bicarb q 90 min. in lieu of his severe
acidosis. Cultures were sent including blood, urine and sputum
to look for source of infection. Patient had been c/o RUQ pain,
however CT abdomen did not show any acute infectious process or
ischemic bowel. He was continued on broad-spectrum antibiotics
including vancomycin and cefipime. He was placed under a
bear-hugger for hypothermia.
.
Patient was severely acidotic with a pH on presentation of 7.17.
This was felt to be a combination of lactic acidosis from liver
failure and possible sepsis. Also acute renal failure
contributing as well. Given his large tumor burden in the liver
it was felt that he may have had necrosis of his tumor as well.
There was no evidence of ischemic bowel. Surgery evaluated him
in the ED and felt there were no acute surgical issues. In
order to manage his severe acidosis his rate on the ventilator
was serially inceased up to a rate of 35 in order to decrease
his CO2. Unfortunately his acidosis was so overwhelming that
his pH was unable to be corrected above 6.9 and RR could not be
increased further due to airway pressures and breath stacking.
The patient was also in ARF with Cr elevated to 6.2 on admission
from baseline of 1.6 prior to chemo. Felt to be ATN in setting
of shock. Also on diuretics and ACE at home which in setting of
hypovolemia likely also contributed. He remained anuric depite
volume resuscitation. The patient was also significantly
coagulopathic on arrival with INR 14.2. This was felt to be [**1-28**]
hepatic failure and impaired synthesis in the setting of large
tumor burden. plts were normal and fibrinogen was elevated so
not DIC, however pt. at high risk of this given malignancy,
infection. Received 2 units of FFP and vit. K in the ED with
correction of his INR to 3.9. The patient also had liver
failure that was felt to be due to his extensive metastatic
disease in liver and also a component of shock liver given
hypotension.
.
Prior to intubation in the ED the patient expressed that he
wanted everything done. Resuscitation was continued in the ICU
as above, however the patient became progressively more acidotic
and hemodynamically unstable. His brother was [**Name (NI) 653**] as the
next of [**Doctor First Name **] and indicated that there was no other family member
or HCP. The patient's blood pressure continued to decline and
vasopressin was started without effect. Given the gravity of
his condition and severe uncorectable acidosis as well as
aggressive metastatic melanoma the ICU team made the patient CPR
not indicated. The patient's brother was in aggreement with
this decision. At 0235 the patient expired due to cardiac
arrest. The patient's brother was notified and declined a
post-mortem exam. The ME was also notified and also declined a
post.
Medications on Admission:
1. Digoxin 125 mcg daily.
2. Diltiazem 180 mg daily.
3. Hydrochlorothiazide 25 mg daily.
4. Vicodin p.r.n. pain.
5. Lisinopril 5 mg daily.
6. Metoprolol 100 mg b.i.d.
7. Serax 30 mg q.4h.
8. Compazine p.r.n. nausea, vomiting.
9. Trazodone 200 mg q.h.s.
10. Aspirin 325 mg daily.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Multiorgan system failure, septic shock, metastatic melanoma
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 0389, 5849, 2762, 4019 | [
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train_30840 | completed | 5e271b62-b7dc-47c5-80bb-66e5e7830a67 | Medical Text: Admission Date: [**2150-4-20**] Discharge Date: [**2150-4-27**]
Date of Birth: [**2096-10-22**] Sex: F
Service: NEUROLOGY
Allergies:
Ativan
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
confusion, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 53 year-old woman who was brought into the ED by
her husband after she was confused and not making sense this
morning at home. She has a notable history of paraplegia
secondary to motor-vehicle accident in [**2142**] with T1/2 cord
injury. She was recently hospitalized from [**4-14**] - [**4-16**] after
she developed yellow productive sputum with a likely right lower
lobe consolidation. She was treated w/ Vancomycin, cefepime and
azithromycin for a healthcare associated pneumonia (HCAP) and
discharged on [**4-16**]. She was also found to have a multidrug
resistant klebsiella UTI and was started on Vanc/Zosyn for a 14
day course.
Her husband and primary caregiver at home felt that the evening
prior to admission she was at her baseline which they describe
as
communicative, pleasant and with mobility in her upper
extremities. On [**4-20**] she awoke stating that she had a bad
headache (further description unobtainable) and she was no
longer
making sense. She continued to repeat phrases and was not
following commands. She was brought into the ED. During her time
in the ED she was noted to have a seizure for around 1 minute
which consisted of deviation of the head to the right with eyes
to the right. She also had tonic contraction of both arms. This
resolved spontaneously and was then given 2 mg of Versed (hx of
adverse reaction to Ativan). Her caregiver reports that she had
one seizure in the past, around 1 year ago in the setting of
multiple medication discontinuation (including - baclofen).
She also has a history of PRES in the setting of a MICU
admission
in [**2147-12-3**] in which systolic blood pressures were greater than
160s. She had binocular vision loss during the episode and MRI
with occipital lobe FLAIR hyperintensities.
She is unable to provide any additional history. Her husband
states that at home her blood pressure typically run in the
90s-110s systolic.
Past Medical History:
# T1 to T2 paraplegia status post a motor vehicle accident.
# Recurrent pneumonia (followed by pulm - Last [**2149-4-9**])
- Per pulm, recurrent pneumonia likely from pulmonary toilet
issues secondary to neuromuscular disease with improvement with
consistent and aggressive bronchopulmonary therapy.
- Prior sputum cultures + for MRSA, pan-sensitive Klebsiella,
and Pseudomonas.
# Recurrent UTIs in the setting of urinary retention requiring
straight catheterization
# COPD
# hepatitis C
# anxiety
# DVT in [**2142**] -IVC filter placed in [**2142**]
# Pulmonary nodules
# Hypothyroidism
# Chronic pain
# Chronic gastritis
# Anemia of chronic disease
# S/p PEA arrest during hospitalization in [**2147-10-3**]
Social History:
Lives at home with husband and 2 adolescent children.
- Tobacco: 35-pack-years, has tried to quit but smokes
intermittently.
- Alcohol: Denies.
- Illicits: Denies.
Family History:
Mom - lung cancer
Dad - healthy
Physical Exam:
afebrile; 116-190s/70s-110s P 90s R 30s SpO2 95% facemask
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: continuously repeating phrases "yes, ok, yes,
ok". Not following simple appendicular or midline commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 2mm and sluggish. blinks to threat b/l.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: eyes midline and will track to the left, not moving
past midline to the right
V: reacts to stimuli on both sides of face
[**Year (4 digits) **]: No facial droop, facial musculature symmetric.
VIII: reacts to auditory stimuli b/l
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: unable to test
XII: unable to test
-Motor: diminished bulk in LE, flaccid tone in LE.
No adventitious movements, such as tremor, noted. Has b/l
movements of arms that are purposeful and symmetric, some
resistance b/l at the triceps. No movement of legs (chronic)
-Sensory: reacting to stimuli on UE b/l
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was muted bilaterally.
-Coordination: unable to test
-Gait: unable to test given paraplegia
.
Exam on discharge:
.
Unchanged except for the following Mental status exam: Alert,
oriented X3, language normal, attention: able to recite months
of year backwards, short-term memory: [**4-5**] words @ 5minutes,
slight perseveration,
Pertinent Results:
Labs on admission:
[**2150-4-20**] 09:45AM PT-12.5 PTT-29.9 INR(PT)-1.2*
[**2150-4-20**] 09:45AM PLT COUNT-218#
[**2150-4-20**] 09:45AM NEUTS-79.0* LYMPHS-14.4* MONOS-2.9 EOS-3.1
BASOS-0.6
[**2150-4-20**] 09:45AM WBC-9.1 RBC-3.84* HGB-10.0* HCT-33.7*# MCV-88
MCH-26.0* MCHC-29.7* RDW-16.4*
[**2150-4-20**] 09:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-4-20**] 09:45AM ALBUMIN-3.8 CALCIUM-9.2 PHOSPHATE-3.8#
MAGNESIUM-2.3
[**2150-4-20**] 09:45AM LIPASE-16
[**2150-4-20**] 09:45AM ALT(SGPT)-30 AST(SGOT)-22 ALK PHOS-78 TOT
BILI-0.2
[**2150-4-20**] 09:45AM GLUCOSE-119* UREA N-9 CREAT-0.5 SODIUM-146*
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-40* ANION GAP-11
[**2150-4-20**] 09:51AM LACTATE-1.0
[**2150-4-20**] 10:17AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2150-4-20**] 10:17AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2150-4-20**] 10:17AM URINE UHOLD-HOLD
[**2150-4-20**] 10:17AM URINE HOURS-RANDOM
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1100*
POLYS-45 LYMPHS-45 MONOS-10
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF) WBC-9 RBC-3*
POLYS-43 LYMPHS-45 MONOS-12
[**2150-4-20**] 12:16PM CEREBROSPINAL FLUID (CSF) PROTEIN-79*
GLUCOSE-71
[**2150-4-20**] 12:35PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-4-20**] 12:35PM URINE HOURS-RANDOM
Imaging studies:
.
[**2150-4-20**]
CT_HEAD
IMPRESSION: Significant motion artifact limits evaluation. White
matter
hypodensity in the left parietal lobe may represent sequela of
prior event of PRES.
.
NOTE ADDED AT ATTENDING REVIEW: Although the left frontal
hypodensity might be a sequelum of prior PRES, the MR
examination of [**2147-12-29**] did not demonstrate abnormality in
this location. Further, there is loss of grey white contrast,
but no atrophy, as might be expected if this were an old lesion.
These findings raise concern of acute-subacute infarction, or
perhaps swelling after a seizure. MR is recommended for further
evaluation. This revised interpretation was noticed at 5:25 pm,
and discussed by telephone, by Dr. [**Last Name (STitle) **], with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22924**]
of the Emergency Department at 5:30pm.
[**2150-4-19**]
EEG
IMPRESSION: This is an abnormal portable EEG due to the presence
of
frequent left temporal and left hemisphere sharp and slow wave
discharges occurring for a few seconds at a time at 1 Hz
indicative of
an epileptogenic focus in this region. However, the study was
severely
limited by abundant and frequent movement artifact during the
majority
of the study, and the rightsided electrodes were most severely
affected. The background was otherwise slow and disorganized
reaching
up to a maximum of [**6-7**] Hz posteriorly indicative of a moderate
to
severe encephalopathy. Given the above findings, we suggest 24
bedside
EEG monitoring for further diagnosis.
[**2150-4-24**]
CT-HEAD
IMPRESSION: Hypodensities in bilateral occipital, left temporal,
and left
frontal lobes are not significantly changed since the prior
exam, and may
represent PRES or post-seizure changes. MRI is recommended for
further
evaluation.
Brief Hospital Course:
Ms. [**Known lastname **] is 53 yo woman with T1-T2 level paraplegia since [**2142**],
with previous history of episode of PRES, was in [**Hospital1 **] with
pneumonia and UTI last week, home for 4 days when she developed
headache and confusion. She came in to ER, was hypertensive to
SBP of 170's-180's and DBP in 110-120 range, had a focal seizure
and severe encephalopathy.
On [**2150-4-20**] she was admitted to the ICU and her hypertension was
treated with nicardipine IV. She was loaded with [**Date Range 13401**] for
possible seizures. She was given Acyclovir empirically for
possibility of HSV encephalitis and underwent a lumbar puncture.
She was treated empirically for MDR UTI and possible PNA with
Vancomycin/Cepefime/Flagyl.
She underwent NCHCT which showed hypodensities consistent with
PRES with possibility of acute-subacute infarct.
Given her overall improvement, she was transfered to the floor
on [**2150-4-22**].
She remained afebrile and her BP was well controlled. Her CSF
did not show HSV and Acyclovir was discontinued. Her other ABx
were also stopped.
On [**2150-4-22**], she had an extended routine EEG which did not show
electrographic seizures or clear spikes. Her [**Date Range 13401**] was
continued for seizure prophylaxis as she did not have any other
episodes concerning for seizure.
To evaluate the hypodensity seen on previous scan, she was
ordered for MRI brain but refused. She was then ordered for a
repeat NCHCT which showed stable changes consistent with PRES.
She will be discharge home to resume her typical pre-admission
home services.
Transitional issues:
.
1. PRES: this is the second episode since [**2147**]. Given her
paraplegia, she is at risk for dysautonomia and hypertensive
crises which have required inpatient hospitalizations for BP
control. Her BP is somewhat labile and attempts to start low
dose BP control meds (lisinopril) have led to significant
hypotension. Going forward, she might benefit from BP cuff with
PRN BP control at home. She should continue her typical home
care to limit pain, constipation or other triggers of
hypertension.
.
2. Pulmonary function: she has chronic recurrent PNA and
followed by Pulmonary service. She has PFTs tomorrow and ongoing
home chest-PT which she will continue on discharge.
.
3. Sleep apnea: during this hospitalization, she had several
episodes of desaturations (80s) at night despite being on 2LNC.
It is [possible that her likely sleep apnea is contributing to
HTN. We will recommend a sleep study as outpatient.
.
4. Seizures: these were likely provoked by PRES. For the moment,
she will remain on [**Name (NI) 13401**] prophylactically until neurology
follow-up.
Medications on Admission:
albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once Daily at 4
PM.
calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
citalopram 40 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO three times a
day as needed for anxiety.
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
Three (3) Adhesive Patches, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Once
Daily at 4 PM.
13. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID
(2 times a day).
14. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One
(1) Powder in Packet PO DAILY (Daily).
15. pregabalin 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO TID (3
times a day).
16. simvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a day.
17. sucralfate 1 gram Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times
a day).
18. oxycodone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
19. trazodone 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
20. azithromycin 250 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
21. prednisone 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO once a day:
Friday, then 1 tablet daily Saturday/Sunday.
Disp:*4 Tablet(s)* Refills:*0*
22. vancomycin 500 mg Recon Soln [**Name (NI) **]: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 23 doses.
Disp:*23 inj* Refills:*0*
23. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
[**Name (NI) **]: One (1) Intravenous Q8H (every 8 hours) for 32 doses.
Disp:*32 inj* Refills:*0*
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Name (NI) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
2. baclofen 10 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID (2 times a
day).
3. baclofen 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q 24H (Every 24
Hours).
4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
[**Name (NI) **]: Two (2) Tablet, Chewable PO twice a day.
5. citalopram 20 mg Tablet [**Name (NI) **]: Two (2) Tablet PO DAILY (Daily).
6. ipratropium bromide 0.02 % Solution [**Name (NI) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for dyspnea.
7. levothyroxine 112 mcg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
8. clonazepam 1 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Name (NI) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. methadone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID (3 times a
day).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Name (NI) **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: Two (2) Tablet PO BID
(2 times a day).
13. oxybutynin chloride 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q24H
(every 24 hours).
14. polyethylene glycol 3350 17 gram Powder in Packet [**Name (NI) **]: One
(1) Powder in Packet PO DAILY (Daily).
15. pregabalin 25 mg Capsule [**Name (NI) **]: Four (4) Capsule PO TID (3
times a day).
16. simvastatin 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
17. sucralfate 1 gram Tablet [**Name (NI) **]: One (1) Tablet PO three times
a day.
18. oxycodone 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for Pain.
19. trazodone 50 mg Tablet [**Name (NI) **]: Two (2) Tablet PO HS (at
bedtime) as needed for anxiety.
20. acetaminophen 650 mg/20.3 mL Solution [**Name (NI) **]: One (1) PO Q6H
(every 6 hours) as needed for headache.
21. levetiracetam 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Encephalopathy
PRES syndrome
seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for confusion and headaches
and were found to have very high blood pressure. You also may
have had a seizure.
You confusion was thought to be the result of either high blood
pressure or the result of an infection. Both your high blood
pressure and possible infection were treated and you improved.
The antibiotics were stopped. An anti-seizure medication was
started.
You were closely monitored over the next several days and your
condition improved every day.
You should follow up with the neurologist once you leave the
hospital.
You should follow up with the Pulmonary doctor once you leave
the hospital given the concern for sleep apnea. You may benefit
from a sleep study to ensure that your oxygen level does not
decrease at night. You should continue respiratory therapeutic
maneuvers every day.
During your hospitalization, you were noted to have several high
blood pressure readings. You should discuss starting a
medication to help treat this.
Please note the following medication changes
START
- [**Hospital1 13401**] (to help prevent seizures, this medication might be
stopped by your neurologist in the future)
STOP:
-
Please continue taking all your other medication as prescribed
by your physicians.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2150-4-30**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2150-4-30**] at 1:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2150-4-30**] at 1:30 PM
With: DRS. [**Name5 (PTitle) 4013**] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Neurology
When: [**2150-5-13**] 02:30p
With: [**Doctor Last Name 43**],[**Doctor Last Name **]
Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] NEUROLOGY UNIT CC8
ICD9 Codes: 496, 5990, 5180, 2449, 2859, 3051, 4019 | [
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train_32930 | completed | a25a3175-3ae3-4b82-8cd6-8b0debc1f454 | Medical Text: Admission Date: [**2139-10-28**] Discharge Date: [**2139-11-7**]
Date of Birth: [**2069-4-14**] Sex: M
Service: MICU-TULLI
CHIEF COMPLAINT: Transferred from outside hospital.
HISTORY OF PRESENT ILLNESS: This is a 70 year old male with
a history of coronary artery disease, aortic stenosis (aortic
valve area 0.99, with a gradient of 68), paroxysmal atrial
fibrillation, and left lobe lung cancer status post left
pneumonectomy. He presented to the outside hospital on
[**2139-10-20**] with a chief complaint of shortness of
breath and dyspnea on exertion and productive cough. The
patient had been diagnosed with pneumonia on [**2139-10-9**], and
started a steroid and Levaquin.
The patient had completed the course of steroid and the
symptoms returned. The patient went to the Emergency
Department in [**Hospital 4415**] where a chest x-ray
showed right lower lobe infiltrate. The patient was treated
as congestive heart failure with Nitroglycerin, lasix and
Bi-PAP with chest PT. The patient's oxygen saturations
dropped and the decision was made to intubate.
CBC showed white blood cell count of 26.8 with a differential
of 83% neutrophils, 10% bands. The sputum culture eventually
grew Pneumococcus. The patient was started on Timentin and
Vancomycin which was subsequently changed to Kefzol and
Zithromax. The patient was extubated on [**10-23**], and
transferred to the floor where he desaturated and required
Bi-PAP. The attending physician requested transfer to [**Hospital1 1444**]. A Swan-Ganz was placed at
the outside hospital on [**2139-10-28**] and showed a pulmonary
capillary wedge pressure of 22. The patient was diuresed
two liters with symptomatic relief. The patient was
re-intubated and transported to [**Hospital1 188**].
PAST MEDICAL HISTORY:
1. Left lung cancer status post pneumonectomy.
2. Coronary artery disease status post percutaneous
transluminal coronary angioplasty in [**2129**].
3. Prostate cancer status post radiation.
4. Osteoarthritis.
5. Hypertension.
6. Hypothyroidism.
7. Aortic stenosis.
8. Paroxysmal atrial fibrillation.
9. Gout.
ALLERGIES: No known drug allergies.
MEDICATIONS AT ADMISSION:
1. Solu-Medrol 30 mg intravenous q. six.
2. Regular insulin sliding scale.
3. Nitroglycerin drip.
4. Nebulizers p.r.n.
5. Allopurinol 100 mg p.o. q. day.
6. Protonix 40 mg p.o. q. day.
7. Zithromax 500 mg p.o. q. day.
8. Digoxin 0.25 mg p.o. q. day.
9. Cozaar 50 mg p.o. q. day.
10. Synthroid 0.075 mg p.o. q. day.
11. Lasix 40 mg intravenously q. day.
12. Epogen 40,000 units q. week.
13. Lovenox 40 mg q. day.
14. Hydralazine 25 mg intravenously q. six hours.
SOCIAL HISTORY: The patient quit smoking 20 years ago; has
about three beers a night. The patient is married with three
children.
PHYSICAL EXAMINATION: Blood pressure 126/51; pulse 84. The
patient is a frail appearing elderly male, intubated, alert
and oriented times three, in no apparent acute distress.
HEENT reveals no icterus, no pallor. Mucous membranes were
moist. Neurological examination shows cranial nerves II
through XII grossly intact. No focal neurological deficits.
Cardiovascular is regular rate and rhythm, positive III/Vi
holosystolic murmur which radiates to the neck bilaterally
and to the left axilla. There is positive jugular venous
distention, positive peripheral pitting edema. No bruits.
Pulmonary examination reveals no breath sounds on the left
and scattered expiratory wheezes on the right with increased
breath sounds anteriorly. Abdominal examination shows a
soft, nontender, nondistended abdomen with normal bowel
sounds.
LABORATORY: Pertinent data on admission was white blood cell
count of 11.9, hematocrit 33.0, platelets 174, neutrophils
94%, digoxin level 1.0. PT 14.8, PTT 27.8, INR 1.5.
Urinalysis was negative. Sodium 147, potassium 3.9, chloride
101, bicarbonate 40, BUN 56, creatinine 0.9, glucose 206,
calcium 7.8, phosphorus 4.1, magnesium 2.3.
EKG showed atrial fibrillation at outside hospital.
Swan-Ganz catheter showed a central venous pressure of 4.0.
Pulmonary artery pressure of 30 to 45 over 10 to 17.
Systemic vascular resistance, [**2045**]. Pulmonary capillary
wedge pressure between 6 and 11. Cardiac output 4.36.
Chest x-ray obtained here shows a decreased right sided
effusion compared to chest x-ray obtained at outside
hospital.
HOSPITAL COURSE:
1. ATRIAL FIBRILLATION: The patient's heart rate alternated
between atrial fibrillation with rapid ventricular response,
atrial fibrillation with a controlled rate, normal sinus
rhythm and sinus tachycardia. The patient was rate
controlled with Diltiazem. Because Diltiazem caused the
patient to become excessively bradycardic (in the 30s), it
was felt that the patient should be rate controlled, but that
a pacemaker should be placed to prevent excessive
bradycardia.
The patient remained in normal sinus rhythm most of the time
but had several episodes of atrial fibrillation with a rapid
ventricular response at a rate of 140. During each of these
episodes, intravenous Diltiazem was pushed and was successful
in controlling the patient's rate. He would become
symptomatic with shortness of breath when he would go into
atrial fibrillation but these symptoms abated with rate
control.
On hospital day six, the patient underwent pacemaker
placement. He tolerated this well and there were no
complications. Diltiazem dose was eventually increased to
240 mg q. day of sustained release and Dofetilide was started
after pacemaker placement. The patient was kept for three
days in-house to be monitored while Dofetilide therapy was
initiated. He tolerated Dofetilide well.
On the evening of the second day of Dofetilide, the patient
developed a one asymptomatic 32-beat run of ventricular
tachycardia. This was felt not to be due to Dofetilide so
much as to the patient's structural heart disease, but the
dose of Dofetilide was decreased.
2. AORTIC STENOSIS: After load reduction was achieved
initially with Losartan 50 mg p.o. q. day with intravenous
Hydralazine being used for acute blood pressure elevations.
Eventually, the patient was put on Losartan 100 mg p.o. q.
day and Hydralazine was no longer necessary for blood
pressure control. The patient's aortic stenosis is not at [**Doctor Last Name **]
level of severity which would necessitate aortic valve
replacement.
3. DYSPNEA: Because of the patient's elevated pulmonary
artery pressure and significant lower extremity edema, he was
felt to be volume overloaded with respect to total body
volume. However, because of the patient's sinus tachycardia,
urine sodium of 20, urine osmolality of greater than 900 and
increased BUN to creatinine ratio of about 50:1 and serum
sodium of greater than 150, the patient was felt to be
intravascularly depleted. Chest x-ray and auscultation
revealed no signs of overt pulmonary failure. The patient
was also able to maintain his saturations. So it was decided
to best mobilize the patient's fluid by placing compression
stockings on his legs and giving him Lasix 40 mg
intravenously q. day. He was encouraged to take p.o. fluids.
The patient did diurese well with improvement in his
shortness of breath and his creatinine remained stable with
resolution of his BUN to creatinine ratio.
His dyspnea was also felt to be at least partly because of
his chronic obstructive pulmonary disease. He was continued
on a Prednisone taper and treated with Atrovent and Albuterol
nebulizers with chest PT. The patient remained afebrile
without a white blood cell count and there was no concern
that his pneumonia had returned.
As the patient continued to diurese, the lasix was decreased
to 30 mg p.o. q. day during his last day of hospitalization.
On the day of discharge, the patient was at 30 mg p.o. q. day
of Prednisone. This was day one of three of the 30 mg dose.
He is to be subsequently tapered by 10 mg every three days.
After the pacemaker placement the patient was restarted on
Coumadin. His INR was 1.5 the day prior to discharge. He is
receiving a dose of 5 mg p.o. q. h.s.
The patient also received Vancomycin for two days when he
received his pacemaker and three days of Keflex after that.
It should also be noted that the patient cannot tolerate beta
blockers or ACE inhibitors. Beta blockers cause bronchospasm
and ACE inhibitors cause angioedema.
4. PHYSICAL THERAPY: The patient was seen by Physical
Therapy and treatment was initiated.
DISCHARGE STATUS: The patient is stable for discharge to a
rehabilitation facility. Since he has only received three
days of Coumadin 5 mg p.o. q. h.s., his PT should be
monitored and his Coumadin adjusted to achieve a therapeutic
INR.
His blood sugars should be closely monitored and covered with
a regular insulin sliding scale, because although the patient
is not diabetic, he has had significant hyperglycemia from
the Prednisone.
Starting [**2139-11-7**], the patient will be on 30 mg p.o. q day
of Prednisone for three days, then 20 mg p.o. q. day of
Prednisone for three days, then 10 mg p.o. q. day of
Prednisone for three days. At that point, his Prednisone
should be discontinued.
The patient's fluid status should also be closely monitored.
He will be sent out on 20 mg p.o. q. day of Lasix. The
patient may need to be maintained on this dose or he may
eventually not need to maintained on Lasix.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. day.
2. Dofetilide 125 micrograms p.o. twice a day.
3. Keflex 500 mg p.o. q. six hours; last dose should be
given in the evening of [**2139-11-7**].
4. Diltiazem Extended Release 240 mg p.o. q. day.
5. Losartan 100 mg p.o. q. day.
6. Atrovent and Albuterol nebulizers, one to two nebulizers
q. four to six hours p.r.n.
7. Coumadin 5 mg p.o. q. h.s.
8. Prednisone 30 mg p.o. q. day to be tapered as indicated
above.
9. Zolpidem tartrate 5 mg p.o. q. h.s. p.r.n. for
sleeplessness.
10. Lansoprazole 30 mg p.o. q. day.
11. Levothyroxine 75 micrograms p.o. q. day.
12. Allopurinol 100 mg p.o. q. day.
13. Fexaphenadine 60 mg p.o. twice a day.
14. Regular insulin sliding scale.
15. Erythropoietin alpha 40,000 units subcutaneously one time
per week on Thursdays.
DISCHARGE DIAGNOSES:
1. Paroxysmal atrial fibrillation status post pacemaker
placement, on Dofetilide and Diltiazem.
2. Non-critical aortic stenosis.
3. Chronic obstructive pulmonary disease.
4. Pneumonia.
5. Left lung cancer status post pneumectomy.
6. Coronary artery disease status post percutaneous
transluminal coronary angioplasty in [**2129**].
7. Prostate cancer status post radiation.
8. Osteoarthritis.
9. Hypertension.
10. Hypothyroidism.
11. Gout.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with his primary care
physician as indicated on the page one referral.
2. The patient is to follow-up with Cardiology as indicated
on the page one referral.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2139-11-6**] 17:42
T: [**2139-11-6**] 19:47
JOB#: [**Job Number 45244**]
ICD9 Codes: 4280, 486, 496, 4241, 2749, 2449, 4019 | [
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train_32620 | completed | d46f777d-3a02-4732-a431-e2cfacc90d1f | Medical Text: Admission Date: [**2113-7-29**] Discharge Date: [**2113-8-1**]
Date of Birth: [**2044-11-30**] Sex: M
Service: Urology
REASON FOR ADMISSION: Admitted for observation after a
nephroureteral stent placement on [**7-28**], after which he
had an episode of hypotension.
HISTORY OF PRESENT ILLNESS: A 68-year-old male with a
ileal loop urinary diversion, who presented with distal left
ureteral obstruction with hydronephrosis and a minimally
functioning right kidney, who had a left nephroureteral stent
placed by IR. Status post procedure, the patient
experienced chills and a drop in blood pressure and became
tachycardic but was afebrile at that time in the operating
room. In the Postanesthesia Care Unit temperature came up to
was admitted for observation.
PAST MEDICAL HISTORY:
1. Bladder [**Last Name (un) 3711**] rwith positive LN's.
2. Hypertension.
PAST SURGICAL HISTORY: Radical cystectomy, ileal loop
diversion.
ALLERGIES: HALDOL and AMBIEN.
MEDICATIONS ON ADMISSION: Atenolol, Prilosec, Colace,
vitamin, psyllium, Benadryl.
PHYSICAL EXAMINATION ON ADMISSION: Physical examination was
unremarkable except for the urostomy which was bloody, status
post stent placement.
LABORATORY ON ADMISSION: Admission white blood cell count
was 11.4.
HOSPITAL COURSE: Later on during the night he became
hypotensive and was bolused until his pressure was
re-established. On [**7-29**], he had a temperature maximum
of 100.3, and 99.5 was his current temperature in the
morning. His blood pressure dropped to 82/45 with a white
blood cell count which increased to 23.8. He was immediately
transferred to the Medical Intensive Care Unit for a more
monitored setting where he was bolused, and his pressures
came up to 100/60, eventually reaching 130s/70s to 150s/70s,
with a heart rate around 90 the following day.
Infectious Disease was consulted, and they advised that we
start the patient on ceftazidime and vancomycin, which was
done. Cultures taken from the patient were still pending and
were negative. The patient was taken to the Medical
Intensive Care Unit on [**7-30**] where it was again noted
that his baseline creatinine was in fact 5, and there was no
acute renal insufficiency.
In the Medical Intensive Care Unit, even though his pressure
was kept up, he was receiving normal saline at 250 cc an hour
and received two to three boluses. His pressures remained
good, and his urine output remained sufficient as well.
On [**7-30**], the patient was then transferred back to the
floor out of the Intensive Care Unit continuing his regimen
of vancomycin and ceftazidime, and his pressure remained
good.
On hospital day three, we found that his 4 a.m. laboratories
returned with a white blood cell count of 23.4 which was up
from a [**7-30**] complete blood count white blood cell
count of 22.7. The decision was made to keep him one more
day for intravenous antibiotics and to discharge him home on
[**8-1**] with p.o. antibiotic regimens.
Follow up with Dr. [**Last Name (STitle) 9125**].
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2113-7-31**] 10:23
T: [**2113-8-2**] 14:07
JOB#: [**Job Number 31909**]
ICD9 Codes: 4019, 2859, 4589 | [
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train_32629 | completed | 6592758a-6954-4c45-99e7-51069432267d | Medical Text: Admission Date: [**2194-1-6**] Discharge Date: [**2194-1-10**]
Date of Birth: [**2126-2-3**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
male who, while being worked up for an abdominal aortic
aneurysm repair, which was 6 x 5 x 5.8 cm, was found to have
two vessel heart disease. The two vessel heart disease with
preserved ejection fraction was right coronary artery
proximally and left anterior descending to past the first
diagonal. He had an ejection fraction of 45%, and some
anteroseptal and anteroapical hypokinesis with trace mitral
regurgitation.
PAST MEDICAL AND SURGICAL HISTORY: Bladder cancer,
hypertension, hypercholesterolemia, abdominal aortic
aneurysm.
MEDICATIONS AT HOME: Lotensin 20 once a day, Cardura 4 once
a day, hydrochlorothiazide 12.5 once a day, Lipitor 60 once a
day, atenolol 50 once a day.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was taken to the operating
room on [**2194-1-6**] as a same day arrival. Please see the
operative note for full details. He was transferred to the
Cardiothoracic Intensive Care Unit postoperatively. He was
doing well and was extubated on the third attempt without
incident. Chest tubes were discontinued inside the Unit, and
he was transferred to the floor on postoperative day number
one.
The Foley was discontinued, and his diet was advanced as
tolerated. The patient was seen by Physical Therapy, and was
doing extremely well postoperatively. Chest x-ray after
removal of the chest tube revealed no pneumothorax. Wires
were discontinued as well. He had some serosanguinous
drainage from his middle thoracic wound, which resolved on
its own. We started Betadine paints for a small wound on the
side as a precaution, however, that turned out to not be
warranted.
The patient's electrolytes were repleted as needed during his
stay, and he was discharged home on [**1-10**] or [**2194-1-11**]. Final
discharge date to be an addendum.
DISCHARGE MEDICATIONS:
1. Cardura 2 mg by mouth once daily
2. Lipitor 60 mg by mouth once daily
3. Aspirin 325 mg by mouth once daily
4. Percocet 40 tablets will be dispensed.
5. Lopressor 25 mg by mouth twice a day
6. Lasix 20 mg by mouth every 12 hours for one week
7. Potassium chloride 20 mEq every 12 hours
8. Colace 100 mg by mouth twice a day
9. Ranitidine 150 mg by mouth twice a day
Up[**Last Name (STitle) 38857**], he is in good condition, with no apparent
complications. He is to follow up with Dr. [**Last Name (Prefixes) **]
within a month, as well as his primary care provider.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2194-1-9**] 22:28
T: [**2194-1-10**] 00:00
JOB#: [**Job Number 38858**]
ICD9 Codes: 4111, 4019, 2720 | [
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train_32358 | completed | 4e3b24ae-0649-4dfe-a73a-8e555d15e911 | Medical Text: Admission Date: [**2158-11-18**] Discharge Date: [**2158-11-21**]
Date of Birth: [**2111-4-11**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Serax
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
CC:[**CC Contact Info 99151**]
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Femoral line placemenent
History of Present Illness:
The patient is a 47 year old man with history of polysubstance
abuse (EtOH, hx of heroin) who initially presented with cough
and chest pain. At that time an EKG was unremarkable and an CXR
was w/o acute process. The patient left AMA prior to further
evaluation was done. After about an hour outside the hospital
the patient called EMS stating that he just took a high dose of
his phenobarbital and was worried about himself. On arrival to
the ED his vitals were T 97.5 HR 78 bp 135/78 RR 16 97%RA. He
was awake and stated to the ED staff that he did not want to
kill himself but that he was "just trying to get high." He was
alert and able to walk around the ED and able to order his own
meal. When the ED attending went to evaluate him he was found to
be minimally responsive. He awoke only to sternal rub. He was
intubated for airway protection (with etomidate and succinyl
choline) without significant decline in his blood pressure per
report. A femoral line was placed for IV access. Serum EtoH was
101. Urine tox was + for benzos, barbituates. An OG tube was
placed and charcoal was administered. He received IVF to
alkalinize the urine.
Admitted to the [**Hospital Unit Name 153**].
Past Medical History:
1. MI in [**2156**]
2. Longstanding EtOH abuse w/ h/o DT's, multiple admissions for
withdrawal +/- seizures, multiple falls while intoxicated.
3. Seizure disorder - since age 12 due to head trauma - h/o
absence, partial, and complex seizures; no h/o status
epilepticus. Since adulthood, seizures have been related to EtOH
use or EtOH withdrawal.
4. S/P R lower lobectomy in [**2156-4-2**] for lung CA. No
chemo/radiation.
5. Hepatitis C (untreated)
6. S/P 2nd & 3rd toe amputations [**2-3**] frostbite
Social History:
Mr. [**Known lastname 4318**] is originally from [**State 350**] and spent the last
one year in [**State 1727**] doing painting contract work with his brother.
[**Name (NI) **] returned to [**Location 86**] 3 months ago and has been living alone in
a rooming house in [**Location (un) 583**]. Mr. [**Known lastname 4318**] is divorced and has a
22 year old daughter.
-EtOH: Started drinking at age 15. He has been hospitalized
multiple times for withdrawal seizures and has had DT's x2. For
the past few weeks, he has been drinking 24-36 beers and [**1-3**]
pint vodka per day. The longest he has been sober is 2 yrs from
[**2146**]-[**2147**].
-Smoking: ~40 pack year history. 2pack/day for 20 years. Quit in
[**2156-4-2**] when diagnosed and treated for lung cancer.
-Illicit Drugs: used cocaine, heroin > 15 years ago; [**Hospital1 18**]
records indicate h/o phenobarbital abuse
-Admits to high risk heterosexual activity
Family History:
-Mother (d. 77) ?????? MI; h/o IDDM, HTN
-Father (d. 81) ?????? MI, Alzheimer's Disease, alcoholic
-Brother ?????? recovering alcoholic, h/o heroin abuse
-Brother ?????? recovering alcoholic
-Sister ?????? grew out of absence seizure disorder
Physical Exam:
Vitals: 97.2 67 155/93 20 100%
vent: AC 650 x 14 PEEP 5 FIO2 0.5
Gen: intubated and sedated. thin. chronically ill appearing
HEENT: ETT in place. dry mucous membranes. PERRL
Neck: EJ fills to thryoid cart
Chest: clear anterior and lat. small chest tube scars to right
lat chest
CV: reg tachy S1/S2 no m/r/g
Abd: flat, soft, NT active bowel sounds. no HSM
Ext: clentched left hand. no c/c/e. 2+ DP bilat
Skin: warm, small abrasions to both knees
Neuro:
-MS: arouses to voice
-CN: pupils reactive, gag reflex present
-Motor: moving all 4 ext spontaneously
-DTR: trace at biceps & patellars
Pertinent Results:
[**2158-11-18**] 09:11AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 09:11AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2158-11-18**] 09:11AM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-18**] 09:11AM URINE HOURS-RANDOM
[**2158-11-18**] 03:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 03:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2158-11-18**] 03:20PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-18**] 03:20PM URINE GR HOLD-HOLD
[**2158-11-18**] 03:20PM URINE HOURS-RANDOM
[**2158-11-18**] 03:20PM URINE HOURS-RANDOM
[**2158-11-18**] 04:06PM PT-11.9 PTT-34.6 INR(PT)-1.0
[**2158-11-18**] 04:06PM PLT COUNT-361
[**2158-11-18**] 04:06PM NEUTS-47.2* LYMPHS-42.3* MONOS-5.0 EOS-4.0
BASOS-1.4
[**2158-11-18**] 04:06PM WBC-4.4 RBC-3.58* HGB-9.8* HCT-30.4* MCV-85#
MCH-27.3 MCHC-32.1 RDW-17.3*
[**2158-11-18**] 04:06PM ASA-NEG ETHANOL-101* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-POS tricyclic-NEG
[**2158-11-18**] 04:06PM PHENOBARB-94* PHENYTOIN-LESS THAN
[**2158-11-18**] 04:06PM OSMOLAL-319*
[**2158-11-18**] 04:06PM FOLATE-7.5
[**2158-11-18**] 04:06PM ALBUMIN-4.4
[**2158-11-18**] 04:06PM LIPASE-34
[**2158-11-18**] 04:06PM ALT(SGPT)-58* AST(SGOT)-68* AMYLASE-33 TOT
BILI-0.2
[**2158-11-18**] 04:06PM estGFR-Using this
[**2158-11-18**] 04:06PM GLUCOSE-75 UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2158-11-18**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2158-11-18**] 04:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2158-11-18**] 04:35PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-11-18**] 04:35PM URINE HOURS-RANDOM
[**2158-11-18**] 07:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2158-11-18**] 07:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2158-11-18**] 07:59PM LACTATE-3.9*
[**2158-11-18**] 07:59PM TYPE-ART PO2-288* PCO2-43 PH-7.42 TOTAL
CO2-29 BASE XS-3
Brief Hospital Course:
The patient is a 47 year old man with hx of polysubstance abuse,
distant seizure d/o, hepatitis, and lung cancer s/p resection
presenting with alcohol/phenobarbitol ingestion complicated by
depressed mental status requiring airway protection, now
extubated
.
# Altered Mental Status: likely secondary to phenobarb ingestion
given markedly elevated level complicated by EtOH and benzos. CT
head negative for intracranial bleeding. Phenobarbital level is
trending down as of time pt. left ama. AMS resolved and
successfuly extubated. At time of leaving AMA, pt. fully alert
and oriented, states that he understands my recommendation that
he stay in hospital for further evaluation and treatment, but
wishes to leave against medical advice.
.
# Phenobarbital overdose: Phenobarbital level is decreasing.
Received charcol treatment. Urine was also alkalanized to
enhance excretion. Recommendation made that he change to
another anti-epileptic, and [**Month/Day/Year **] input sought regarding
this, however, pt. left ama before [**Month/Day/Year **] could come to
review the case and evaluate pt.
.
# Respiratory Failure - secondary to altered mental status from
above. no evidence of hypoxia or hypercarbic respiratory
failure. successfuly extubated as mentioned above. At time of
leaving ama, pt. breathing comfortably, saturations on room air
98%.
.
# EtOH Addiction - patient at high risk for DTs given long
history of EtOH addiction and concurrent primary seizure
disorder. Was maintained on valium prn ciwa greater than 10.
At time of discharge, VSS, minimally tremulous. Again, pt
stated understanding that he at high risk of recurrent seizure,
and that he wants to leave despite this risk. I have
recommended evaluation by [**Month/Day/Year **] for recommendations for
anti-epileptic medication other than phenobarbital, but pt.
unwilling to wait for evaluation.
.
# Seizure d/o - no evidence for active seizures at time of d/c
ama.
Medications on Admission:
- Phenobarbital 60mg TID
- Phenytoin 400mg daily
- ASA 81mg daily
Discharge Medications:
None given as pt. left against medical advice.
Discharge Disposition:
Home
Discharge Diagnosis:
alcohol intoxication
alcohol withdrawal
phenobarbital overdose
seizure disorder
Discharge Condition:
AF VSS, withdrawing from alcohol.
Discharge Instructions:
You were admitted because of alcohol intoxication and overdosing
on your phenobarbital. You were intubated and extubated safely.
You are at very very high risk of withdrawing from alcohol,
DT's and even death if you do not either stay here or go to a
drug rehabilitation center for detox. You stated that you
understood this risk and are willing to accept this. You will
need to sign out against medical advice because we strongly
disagree with your decision. We also feel that you need to
change your anti-seizure meds from phenobarbital to dilantin
(which other providers have told you) because you are clearly
abusing the phenobarbital. Please see the provider of these
medications for a firm regimen.
Followup Instructions:
with your PCP [**Last Name (NamePattern4) **] [**1-3**] weeks
ICD9 Codes: 2762 | [
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train_31864 | completed | 71efc6a3-cf27-4182-8ce1-34fa5b4fc909 | Medical Text: Admission Date: [**2191-2-1**] Discharge Date: [**2191-2-4**]
Date of Birth: [**2131-12-4**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
gentleman who had left arm and leg weakness who was found by
MRI to have a right posterior communicating artery aneurysm.
The patient was admitted the week of [**2191-1-30**] for possible
coiling which was unsuccessful because the aneurysm neck was too
wide. The patient subsequently was scheduled for a right patronal
craniotomy for clipping of an aneurysm on [**2191-2-1**] for which he
had no intraoperative complications.
PAST MEDICAL HISTORY:
1. Hypertension
2. Right leg fracture
3. Deep venous thrombosis
5. Hypercholesterolemia
6. Colon polyps
PAST SURGICAL HISTORY:
1. Status post tonsillar adenoidectomy
2. Closed reduction of right lower leg
ALLERGIES: AMPICILLIN AND IODINE, SHELLFISH
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 116/92, heart rate 80.
GENERAL: He was a well appearing gentleman in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: His tympanic membranes
were clear and he had no lymphadenopathy.
CHEST: Clear to auscultation.
CARDIAC: Apical rate of 80, regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended, positive bowel
sounds.
EXTREMITIES: Motor strength was [**3-20**] in all muscle groups.
He had 2+ reflexes throughout.
HOSPITAL COURSE: He is scheduled for a craniotomy for
clipping of a right fetal posterior cerebral artery
origin aneurysm. There were no intraoperative complications. On
postoperative, the patient was monitored in the Surgical
Intensive Care Unit where he was awake, alert and oriented
x3, moving all extremities strongly with no drift. EOMs were
full. Tongue was midline, smile symmetric and sensation was
intact to light touch. The patient was transferred to the
regular floor on postoperative day #1. His vital signs were
stable. He was out of bed and ambulating. On postoperative
day #3, he had a repeat angiogram which showed no residual
aneurysm and good clip position. The patient tolerated the
procedure well without complication and was discharged to
home in stable condition.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg po q day
2. Hydrochlorothiazide 50 mg po q day
3. Percocet 1 to 2 tablets po q4h prn
4. Decadron 4 mg po q6h x8 doses
5. Benadryl 25 mg po q8h x3 doses
The patient's groin site was clean, dry and intact. He has
positive pedal pulses. He was discharged in stable condition
with follow up with Dr. [**Last Name (STitle) 1132**] in one month's time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2191-2-4**] 13:56
T: [**2191-2-7**] 10:41
JOB#: [**Job Number 38935**]
ICD9 Codes: 4019, 2720 | [
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train_28210 | completed | 4330b665-cd07-4b85-b54a-7c2da09c4257 | Medical Text: Admission Date: [**2180-7-16**] Discharge Date: [**2180-7-23**]
Date of Birth: [**2113-2-2**] Sex: M
Service: MEDICINE
Allergies:
Hmg-Coa Reductase Inhibitors (Statins)
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Percutaneous coronary intervention
Intubation in the CCU
A-line placement in the CCU
History of Present Illness:
Mr. [**Known lastname 105222**] is a 67 yo man with CAD s/p CABG in [**2172**] with re-do
in [**2-/2180**] admitted to [**Hospital 1121**] Hospital on [**7-15**] for "sudden
onset shortness of breath." At that time, he complained of
diaphoresis but denied chest pain. He was found to have
pulmonary edema and was given lasix, aspirin, and nitro. He
required intubation in the ED, with an ECG showing RBBB and
ST-elevations. He was given azithromycin and rocephin for
question of infiltrate on CXR.
.
Following intubation and initiation of propofol, his SBP dropped
to the 80s and he had bradycardia with subsequent asystole. He
received CPR for 8-10 minutes and was transferred to the ICU
where he was started on cardiac cooling and initiated on
dopamine gtt. UOP was approximately 30cc/hr, CEs showed trops
0.2 to 0.4 with flat CK. Cardiology was consulted and the
patient was started on a heparin gtt for presumed ACS. He was
diagnosed with "CHF with flash pulmonary edema" s/p cardiac
arrest. [**Month/Year (2) **] was done that showed EF of 30% with severe MR,
inferior akinesis and hypokinesis. Creatinine was up to 3.6 from
the patient's baseline of ~3. There was concern for "anoxic
encephalopathy" but neurology consult was deferred due to
transfer to [**Hospital1 18**] CCU.
.
At time of transfer to [**Hospital1 18**] CCU, he was intubated and moving
all extremities but not responsive. He was afebrile with a SBP
of 110/70, HR 80, ambu-bag with transition to vent, RIJ in
place, with dopamine drip running.
.
Of note, he had been admitted to [**Hospital1 18**] CCU [**2180-2-23**] with DOE after
having been previously evaluated at [**Hospital3 1443**] for
concern for unstable angina.
Past Medical History:
# CAD with 5-vessel CABG in [**2172**]
# MI with PCI [**2172**], PCI in [**5-/2179**] (DES to RCA)
# Left renal artery stenosis [**12/2179**], nuclear scan showed 82%
function on R and 16% function on L; 99% stenosis on renal
angiogram with BMS X1
# CRI ([**1-/2180**] Cr 2.2)
# HTN
# Hemmorhoids
# Hypercholesterolemia
# PVD
# H/o liver lesions
# S/p rectal prolapse repair
# Known carotid disease 16-49% stenosis on R, 50-79% on left
# /p herniorrhaphy
.
CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
.
CARDIAC HISTORY: CABG, in [**2172**] anatomy as follows: LIMA->LAD,
SVG to PDA, OM1, OM2, and diag.
.
PERCUTANEOUS CORONARY INTERVENTION in [**2177**] anatomy as follows:
total occlusion of native vessels and LIMA, with patent SVG to
diag which backfilled LAD. 40% stenosis in SVG to OM.
Social History:
Social history is significant for current tobacco use (52 pack
year smoking history). There is no history of alcohol abuse.
Family history was not elicited.
Family History:
NC
Physical Exam:
VS: T 98.0, BP 110/67, HR 80, RR 18, 98% on vent
Gen: middle aged male intubated, sedated
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CV: no murmurs appreciated, distant, on vent, difficult exam
Chest: No chest wall deformities, scoliosis or kyphosis. mild
upper airway sounds, +crackles R base
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: PERRL, EOMI, + gag, + corneal, moves all 4 ext.
spontaneously, as well as with stimulation.
Pertinent Results:
[**2180-7-16**] 04:58PM
WBC-13.2* RBC-3.51* HGB-10.4* HCT-30.9* MCV-88 MCH-29.7
MCHC-33.7 RDW-15.2
CK-MB-NotDone cTropnT-0.32*
ALT(SGPT)-35 AST(SGOT)-42* LD(LDH)-479* CK(CPK)-87 ALK PHOS-108
TOT BILI-0.5
PT-15.7* PTT-32.8 INR(PT)-1.4*
GLUCOSE-94 UREA N-51* CREAT-3.9* SODIUM-139 POTASSIUM-5.6*
CHLORIDE-110* TOTAL CO2-17* ANION GAP-18
.
[**2180-7-16**] 10:25PM TYPE-ART TEMP-37.2 RATES-/20 PEEP-5 O2-50
PO2-106* PCO2-37 PH-7.32* TOTAL CO2-20* BASE XS--6
INTUBATED-INTUBATED VENT-SPONTANEOUS
[**2180-7-16**] 04:58PM BLOOD CK-MB-NotDone cTropnT-0.32*
.
[**2180-7-20**] 07:31AM BLOOD Type-ART pO2-138* pCO2-53* pH-7.20*
calTCO2-22 Base XS--7
[**2180-7-20**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2180-7-20**] 12:30PM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2180-7-20**] 05:15AM BLOOD Glucose-97 UreaN-44* Creat-2.9* Na-143
K-3.7 Cl-112* HCO3-23 AnGap-12
.
[**2180-7-21**] CK 30, trop T 0.18
.
[**2180-7-22**] Hct 30.9; BUN 45, Cr 3.5;
..
MRI Chest [**2180-7-19**]
FINDINGS: There is no thoracic aortic dissection. The thoracic
aorta is normal in caliber throughout. Ascending aorta measures
approximately 3.2 cm in caliber. Incidental note is made of an
aberrant right subclavian artery.
The pulmonary artery is normal in caliber, with the main
pulmonary artery
measuring approximately 2.7 cm. The heart is not enlarged.
There is no pericardial effusion. Note is made of mitral
regurgitation. There is bilateral, right greater than left,
effusions and atelectasis / consolidation. Note is made of a
sternotomy, consistent with history of previous CABG. Please
note that the graft is not evaluated. Renal arteries cannot be
assessed due to patient's inability to tolerate further
scanning. Limited views of the kidneys from a localizer images
demonstrate atrophy of the left kidney. Left kidney measures
approximately 7 cm in length. Right kidney measures
approximately 9 cm in length.
IMPRESSION:
1. No thoracic aortic dissection or aneurysm.
2. Bilateral, right greater than left, effusions and atalectasis
versus
consolidation.
3. Mitral regurgitation.
..
RENAL U/S [**2180-7-19**]
FINDINGS:
The right kidney measures 9.6 cm. Normal color vascularity and
waveforms are seen throughout the right kidney. The study of the
left kidney is somewhat limited. The cortex is thinned. The left
kidney measures 7.6 cm. There is a cyst located in the mid
portion of the kidney measuring 1.2 x 0.8 x 0.9 cm and is stable
in appearance. A normal sharp systolic upstroke is seen in the
left main renal artery with a peak systolic velocity of 46
cm/sec, essentially unchanged since the prior scan. Intrarenal
waveforms on the left kidney are limited. The left renal vein is
patent.
IMPRESSION:
1. Limited study of the left kidney. Normal waveforms in the
left renal
artery, not significantly changed since prior scan. Left renal
vein patent.
2. Left renal cyst, unchanged.
..
CARDIAC CATH [**2180-7-20**]
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated native 3 vessel coronary artery disease. The LMCA
was
patent. The LAD was occluded at the ostium with disteal vessel
filled
via SVG wth no significant distal disease. The LCX had 95%
proximal
lesion with vessel filling AV LCX and collaterals to distal RCA.
The
grafted OM branches were occluded from the LCX. The RCA was not
injected. The PDA was a small vessel filled from SVG and the
distal RCA
was occluded filing faintly from the SVG-RPDA and from the LCX
collaterals. The SVG-D1 from initial CABG revealed mild disease.
The
SVG-OM from prior CABG revealed long segment with mid disease to
60% and
distally filled very small segment of OM. The SVG-LAD was
normal. The
SVG-RPDA had long segment proximal/mid idsease to less than 50A%
filled
small PDA. The SVG-OM had proximal 70% stenosis and 95% lesion
just
distal to the SVG in OM.
2. Limited resting hemodynamics were performed. The left sided
filling
pressures were elevated measuring 24mmHg. The systemic arterial
pressures were normal measuring 119/51mmHg. There were no
significant
gradient across the aortic valve upon pull back of the catheter
from the
left ventricle into the ascending aorta.
3. Successful PTCA and stenting of the SVG-OM with 2.25x8mm
Minivision
stent and a 2.5x12mm Xience stent which was post dilated to
3.0mm. Final
angiography revealed no residual stenosis, no angiographically
apparent
dissection and TIMI III flow (see PTCA comments).
4. Successful PTCA and stenting of the LCX with a 2.5x12mm
Xience stent.
Final angiography revealed no residual stenosis, no
angiographically
apparent dissection and TIMI III flow (see PTCA comments).
.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. Patent SVG-OM and SVG-D from first CABG.
3. Patent SVG-LAD, SVG-OM and SVG-RCA from redo CABG.
4. Successful PTCA and stenting of the SVG-OM.
5. Successful PTCA and stenting of the proximal LCX.
Brief Hospital Course:
In summary, this is a 67 yo male with h/o CAD s/p CABG, PVD, who
presented to OSH with acute SOB, intubated with asystole, s/p
cardiac arrest, transferred to [**Hospital1 18**] on [**7-16**] for pulmonary
edema, cardiac arrest and renal failure.
.
# CAD/ISCHEMIA: Initially he required pressors but these were
quickly weaned and he was extubated by HD 2. His cardiac enzymes
continued to trend down and his EKG remained stable so he was
maintained on ASA and plavix and was changed to SQ heparin and
transferred to the step down unit. An MRI of the chest was
performed which showed no aortic dissection and no aneurysm. On
[**2180-6-18**], he developed acute diaphoresis with ST depressions in
the antero-lateral leads (consistent with posterior ST
elevation) and he was started on a heparin and nitroglycerin
drip; his diaphoresis and EKG changes improved medically. Our
impressin was circumflex territory ischemia and ischemic mitral
regurgitation and plans were made for cardica cath the next
morning. However, that evening he developed flash pulmonary
edema with hypertension and sinus tachycardia with a minor
increase in cardiac enzymes; he was intubated w/o complications
and he was sent to cath lab. There he underwent successful
stenting of his SVG-OM graft and the proximal circumflex artery.
His CE peaked at a CK of 30 and troponin of 0.19. He remained CP
free after the cath and his enzymes continued to trend down. He
was maintained on plavix and ASA; statins were held as he has an
allergic hx and ACE inhibitor was not given as he had ARF.
.
# PUMP/VALVES: [**Date Range **] performed at [**Hospital1 18**] showed an EF of 40-45%
with left ventricular dysfunction and mild mitral regurgitation.
The mitral valve annuplasty was well-seated. Carvedilol was
increased to 12.5 mg twice daily with consequent hypotension
that was responsive to fluids. The dose was decreased to 6.25mg
twice daily and he was maintained at that dose without further
problems during his hospital stay. The evening of [**2180-6-18**], he
developed pulmonary edema that was treated as above. Post cath,
there were no hyper- or hypotension concerns.
.
# RHYTHM: His rhythm remained in sinus during his
hospitalization and amiodarone was not deemed necessary,
especially given his prolonged QTc. He was maintained on
carvedilol for cardiac protection.
.
# RESPIRATORY FAILURE: He initially presented with SOB, likely
due to sys/[**Last Name (un) **] CHF, now with superimposed insult s/p cardiac
arrest. Although initially he was given Abx at the OSH, they
were not continued as he was afebrile and without a white count.
ABG at admission showed good oxygenation, PS of 5, PEEP 5; he
was extubated on HD 2 and was satting well on RA. He later
developed hypoxic respiratory failure during his flash pulmonary
edema that resolved after diuresis and intubation. His oxygen
was weaned down after extubation within 24 hrs. He continued to
have O2 sats >95% on RA. He continued to have a slight
right-sided pleural effusion with crackles at discharge that was
non-symptomatic and likely residual from his flash edema.
.
# NEUROLOGICAL: Post-extubation and off sedation, his
neurological status was normal and he had no further issues.
.
# CRI/HYPERKALEMIA: He initially presented with acute on chronic
renal failure with a creatinine up to 4. The patency of his left
renal artery stent was found to be normal by Doppler US and the
cause was likely pre-renal due to decreased renal perfusion in
the setting of myocardial ischemia and LV dysfunction. He
required Kayexelate x1 and his electrolytes were repleted as
necessary. Nephrology was consulted and they suggested avoidance
of nephrotoxic drugs with careful diuresis; they saw no
indication for dialysis. Post emergent cath, his creatinine
trended down to baseline and his UOP was maintained well. We
decided to discontinue his Lasix as he was not deemed a baseline
CHF patient.
.
PPx: He was maintained on anticoagulation, either
therapeutically or prophylactic doses throughout his admission.
By discharge, he was ambulating well and DVT prophylaxis was
discontinued.
Medications on Admission:
1. amio 200mg qd
2. plavix 75mg qd
3. asa 81mg qd
4. phoslo
5. carvedilol 6.25mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Unstable angina
Pulmonary edema due to myocardial ischemia and ischemic mitral
regurgitation
Acute on chronic renal insufficiency
Successful PCI SVG to OM and native Circumflex
Discharge Condition:
Asymptomatic and hemodynamically stable.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
shortness of breath. Your shortness of breath was due to fluid
in you lungs. The trigger for this was cardiac ischemia due to
blockage in arteries supplying blood to your heart. You had a
procedure called cardiac catheterization. You had stents placed
to these blockages.
.
Please take the medications as written. It is very important
that you take aspirin 325 mg and plavix 75 mg daily to prevent
clotting of these stents. Please do not stop either of these
medications unless instructed to do so by your cardiologist.
.
Please keep all of your follow up appointments.
.
If you develop chest pain, shortness of breath or any other
concerning symptoms, please call your primary care doctor or go
to the nearest Emergency Department.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Followup Instructions:
Please follow up with your primary care doctor within one week
of discharge.
.
Please follow up with your cardiologist (Dr. [**First Name (STitle) 3236**], phone #
[**Telephone/Fax (1) 11554**]) within one week of discharge.
Completed by:[**2180-7-25**]
ICD9 Codes: 5849, 4275, 4111, 9971, 5185, 5845, 4280, 5859 | [
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train_26542 | completed | 09732fa8-a416-490a-a7b9-14c4c2356388 | Medical Text: Admission Date: [**2165-6-30**] Discharge Date: [**2165-6-30**]
Date of Birth: [**2105-5-25**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
gentleman with diabetes, cerebral palsy, and cardiomyopathy
presenting from an outside hospital in cardiopulmonary shock.
In [**2160**], the patient had a cardiac catheterization at [**Hospital 14852**] which revealed severe 3-vessel disease
with preserved left ventricular function. At that time, he
underwent percutaneous transluminal coronary angioplasty and
stenting of his left circumflex artery. Since that time, he
has been managed medically for chronic exertional dyspnea.
On the morning of admission, he awoke around 2 a.m.
complaining of chest pain and diaphoresis. He took an
aspirin and nitroglycerin with no relief and decided to
present to [**Hospital6 3872**] at approximately 9 a.m..
There, an electrocardiogram revealed an inferoposterior
myocardial infarction. At that time, his systolic blood
pressure was in the 90s. He was seen by a cardiologist, and
plans were made for emergent transfer to [**Hospital1 346**] for primary angioplasty. While
awaiting transfer, the patient's blood pressure dropped to
the 60s; requiring dopamine and Neo-Synephrine as a drip. He
was stabilized and transported via med-flight.
On arrival, the patient was ill-appearing but able to answer
questions. He had ongoing 7/10 chest pain, and his systolic
blood pressure was in the 80s. Given increasing respiratory
distress, the decision was made to semi-electively intubate
the patient. During the intubation, the patient had a
bradycardia arrest with a heart rate down to the 20s, and no
measurable systolic blood pressure. Epinephrine and atropine
were given, and an intra-aortic balloon pump was placed. His
heart rate returned to the 100s, and his systolic blood
pressure returned to the 90s.
An angioplasty was subsequently performed and demonstrated
3-vessel disease with total occlusion of the proximal left
circumflex artery which was treated with a stent. During the
procedure, he was noted to have junctional bradycardia with
complete heart block and frequent episodes of ventricular
tachycardia requiring treatment with amiodarone 150-mg
boluses.
MEDICATIONS ON ADMISSION: (His medications at home included)
1. Aspirin 325 mg by mouth once per day.
2. Atenolol 100 mg by mouth twice per day.
3. Lipitor 40 mg by mouth once per day.
4. Diltiazem 120 mg by mouth once per day.
5. Imdur 60 mg by mouth once per day.
6. Tricor 160 mg by mouth once per day.
7. Avapro 150 mg by mouth once per day.
8. Glucophage 850 mg by mouth twice per day.
9. Folate 1 mg by mouth every day.
10. Glucotrol 20 mg by mouth twice per day.
11. Actos 40 mg by mouth once per day.
12. Zoloft 50 mg by mouth once per day.
ALLERGIES:
PERTINENT LABORATORY VALUES ON PRESENTATION: His laboratory
values were significant for an arterial blood gas which
showed a pH of 7.18, a PCO2 of 40, and a PO2 of 57. This
arterial blood gas was taken while the patient was intubated.
PHYSICAL EXAMINATION ON PRESENTATION: The physical
examination was significant for fixed and dilated pupils. No
breath sounds. No heart sounds after three minutes of
auscultation. No response to verbal or painful stimuli
including sternal rub.
HOSPITAL COURSE: The Coronary Care Unit team was called to
evaluate the patient for unresponsiveness given that the
patient's telemetry and arterial line readings indicated
asystole. All medications and mechanical ventilation were
discontinued, as per the family's wishes in light of the
patient's profound hypoxia, hypotension, and poor prognosis;
status post cardiac arrest.
The patient was pronounced dead at 4:50 p.m. The family was
notified. The Medical Examiner was [**Name (NI) 653**], as the patient
expired less than 24 hours into the admission. The Medical
Examiner declined to pursue the case further.
CONDITION AT DISCHARGE: Deceased.
DISCHARGE STATUS: Not applicable.
DISCHARGE DIAGNOSIS: Cardiopulmonary arrest.
MEDICATIONS ON DISCHARGE: Not applicable.
DISCHARGE INSTRUCTIONS/FOLLOWUP: No applicable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 3809**]
MEDQUIST36
D: [**2165-7-19**] 14:41
T: [**2165-7-30**] 16:06
JOB#: [**Job Number 52286**]
ICD9 Codes: 4280, 9971, 4271, 4019 | [
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train_27252 | completed | 0dbe25db-1123-4f85-a1bd-b704ecb2c5c6 | Medical Text: Admission Date: [**2141-12-14**] Discharge Date: [**2141-12-19**]
Date of Birth: [**2098-9-9**] Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl
Attending:[**Doctor First Name 5188**]
Chief Complaint:
acute cholecystitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname 39729**] is a 43 year old woman with a h/o acute
cholecystitis who is [**Known lastname 1988**] for an elective cholecystectomy
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2141-12-25**]. However, she comes into
[**Hospital1 18**] complaining of intractable RUQ pain x 24 hours, that is
worse with food consumption, and unrelieved with oral pain
medications.
In the ED, a RUQ was performed and was consistent with acute
cholecystitis. The patient denies fevers or chills. She denies
SOB, CP, N/V/D.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Chronic fatigue
4. Chronic headaches
5. Fibromyalgia
6. Depression/Anxiety
7. Talus fracture
8. Cervical cancer
9. GERD
10. Hydronephrosis
11. Mild COPD
14. Chronic mesenteric ischemia - known occlusion of SMA and
celiac, [**Female First Name (un) 899**] was re-implanted in [**2140-6-3**] by [**Year (4 digits) 1106**] surgery
[**48**]. Recent admission [**7-10**] for ? TIA - foudn to have
microvascular
infarcts on MRI and HTN.
16. Admission for GI bleeding, antral ulcers
Social History:
History of heavy alcohol, stopped in [**2136**]. 20 pack year smoking
history, has quit recently. Works as proofreader. No drug use
Family History:
Mother and aunt with coronary artery disease and carotid
disease. Both parents died of lung cancer, mother at age 73,
father at age 68.
Physical Exam:
On admission:
VS: Afebrile, VSS
NAD, WDWN, AAOx3
RRR, S1S2
CTAB
Soft, non-distended, exquisitely tender in the RUQ and
epigastrium. No rebound. Mininmal voluntary guarding. Normal
bowel sounds. Old laparatomy scar is noted and is C/D/I.
No C/C/E
Pertinent Results:
[**2141-12-14**] 01:30PM BLOOD WBC-17.2* RBC-3.51* Hgb-12.1 Hct-34.9*
MCV-100* MCH-34.6* MCHC-34.8 RDW-12.5 Plt Ct-288
[**2141-12-14**] 10:30PM BLOOD WBC-10.0 RBC-2.92* Hgb-9.8* Hct-30.3*
MCV-104* MCH-33.6* MCHC-32.4 RDW-11.9 Plt Ct-203
[**2141-12-15**] 04:33AM BLOOD WBC-9.6 RBC-2.86* Hgb-10.0* Hct-29.4*
MCV-103* MCH-34.9* MCHC-34.0 RDW-12.0 Plt Ct-239
[**2141-12-17**] 06:25AM BLOOD WBC-7.0 RBC-3.20* Hgb-10.8* Hct-32.5*
MCV-101* MCH-33.8* MCHC-33.3 RDW-12.1 Plt Ct-270
[**2141-12-14**] 01:30PM BLOOD Neuts-72.5* Lymphs-19.2 Monos-7.4 Eos-0.7
Baso-0.3
[**2141-12-14**] 10:30PM BLOOD Neuts-53.8 Lymphs-34.2 Monos-9.7 Eos-1.8
Baso-0.4
[**2141-12-14**] 01:30PM BLOOD Plt Ct-288
[**2141-12-14**] 10:30PM BLOOD PT-13.2 PTT-30.9 INR(PT)-1.1
[**2141-12-17**] 06:15PM BLOOD PT-12.8 PTT-36.1* INR(PT)-1.1
[**2141-12-14**] 01:30PM BLOOD Glucose-89 UreaN-8 Creat-0.8 Na-137 K-3.5
Cl-100 HCO3-26 AnGap-15
[**2141-12-14**] 10:30PM BLOOD Glucose-86 UreaN-5* Creat-0.7 Na-142
K-3.5 Cl-114* HCO3-21* AnGap-11
[**2141-12-15**] 04:33AM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-141
K-4.0 Cl-112* HCO3-22 AnGap-11
[**2141-12-17**] 06:25AM BLOOD Glucose-97 UreaN-3* Creat-0.8 Na-140
K-4.1 Cl-104 HCO3-29 AnGap-11
[**2141-12-14**] 01:30PM BLOOD ALT-20 AST-27 AlkPhos-117 TotBili-0.3
[**2141-12-14**] 10:30PM BLOOD ALT-13 AST-18 AlkPhos-89 TotBili-0.3
[**2141-12-15**] 04:33AM BLOOD ALT-17 AST-23 AlkPhos-97 TotBili-0.4
[**2141-12-17**] 06:25AM BLOOD ALT-18 AST-23 LD(LDH)-161 AlkPhos-210*
TotBili-0.4
[**2141-12-14**] 10:30PM BLOOD Calcium-7.2* Phos-2.2*# Mg-1.4*
[**2141-12-15**] 04:33AM BLOOD Calcium-7.5* Phos-2.7 Mg-3.4*
[**2141-12-17**] 06:25AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
[**2141-12-15**] 04:33AM BLOOD VitB12-241 Folate-17.1
[**2141-12-14**] 04:00PM BLOOD Lactate-1.0
RUQ U/S [**12-14**]:
IMPRESSION: Findings worrisome for acute cholecystitis. The
appearance of the gallbladder is similar to the ultrasound from
[**2141-10-18**] at which time the patient also had evidence of acute
cholecystitis.
Brief Hospital Course:
The patient was admited from the ED at [**Hospital1 18**] after she was found
to have a RUQ U/S consistent with acute cholecystitis. She was
also noted to have a leukocytosis. She was admitted to the 5
[**Hospital Ward Name 1950**] floor for further evaluation and treatment.
She was deemed to be a poor operative candidate, and it was
decided to treat her with conservative medical management,
including NPO/IVF and IV antibiotics. She was initially treate
with IV vanco and zosyn.
She remaind NPO until HD 3 where she began tolerating sips of
clear liquids. On HD 4 she began tolerating clear liquids. On HD
6 she was tolerating solid food.
Pain: Her pain was controlled with IV narcotics, and then PO
narcotics when she began tolerating PO.
She was ambulating througout her hospital course.
She was discharged to home in good and stable condition on HD 6.
She was given prescriptions for PO pain medication and
antibiotics.
Medications on Admission:
Fluoxetine 20 mg, Simvastatin 20 mg qday, Loperamide 4 mg qam,
Dicyclomine 20mg qid, Metoprolol Succinate 25 mg Tablet
Sustained Release 24 hr qday
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
Disp:*30 Capsule(s)* Refills:*2*
5. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
8. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
9. Omnicef 300 mg Capsule Sig: Two (2) Capsule PO once a day for
14 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute, chronic cholecystitis
Hypertension
Hyperlipidemia
Chronic fatigue
Chronic headaches
Fibromyalgia
Depression
Anxiety
Talus fracture
Cervical cancer
Gastroesophageal reflux
Hydronephrosis
Cobstructive pulmonary disease
Chronic mesenteric ischemia with occlusion of the SMA, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 899**]
reimplantation ([**June 2140**])
microvascular TIA
Peptic ulcer disease, s/p Ileocecectomy for mesenteric ischemia
Discharge Condition:
good
Discharge Instructions:
Seek medical care for increased abdominal pain, nausea,
vomitting, persistent fevers, or anything else concerning to
you. Do not drink alcohol or drive while taking narcotic pain
medications
Followup Instructions:
Call the office of Dr. [**Last Name (STitle) 39733**] to schedule a follow-up
appointment in [**7-13**] days and to arrange for your planned
cholecystectomy (removal of gallbladder) at a later date
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2141-12-29**]
ICD9 Codes: 496, 2724, 4019 | [
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train_25641 | completed | 11734532-4502-4c57-9512-822d89578c48 | Medical Text: Admission Date: [**2106-9-10**] Discharge Date: [**2106-9-14**]
Date of Birth: [**2087-12-14**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: This [**Hospital1 **]
admission for this 20-year-old man was occasioned by a motor
vehicle accident versus a tree. He was extracted at the site
by Emergency Medical Teams with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of 3 at
the scene. He was in the back seat and unrestrained. He was
transferred to [**Hospital3 **] after a failed attempt to
intubate. He was resuscitated and then flown by EMS crew to
[**Hospital6 256**] for further care. After
successful but difficult intubation, he received six units of
packed cells in the [**Hospital6 256**]
Emergency Unit and stabilized hemodynamically. Chest x-ray
showed right pneumothorax and two chest tubes were placed
bilaterally. Emergent head CT also revealed diffuse
intracranial hemorrhage. He was transferred to the Trauma
Surgical Intensive Care Unit in guarded condition.
PHYSICAL EXAMINATION: He was intubated and sedated and
temperature was 97.5. Blood pressure 166/81. Pulse of 180.
Pupils were fixed, 2+ bilaterally. He had a GCS of 3. He
had a C collar in place. His chest was clear bilaterally.
He had a regular rate and rhythm. His abdomen was soft and
he had left lower extremity abrasion.
An EPL was performed and showed clear return of fluid, no
gross blood.
CT of his head showed diffuse punctate bleeds.
It was thought that he had tachycardia secondary to
contusion. He exacerbated by acidosis and supportive care
was initiated. Mannitol was given. He was felt to have a
pulmonary contusion as well. A CT scan was obtained and a
bolt was placed for monitoring intracranial pressure.
On hospital day two, he received two chest tubes for low
saturations. Mannitol was continued and he was given
Venodynes. Supportive care continued. His CPK was measured
at 711 with an MB of 6. He was started on trophic tube feeds
and on [**9-13**], he was noted to have an increase in
temperature and increasing vasopressor requirements and
worsening metabolic status consistent with sepsis, and so he
had worsening clinical picture in the end.
The intracranial pressure went up and he was thought to have
a poor prognosis secondary to his neurologic injury.
At 12:35 on [**9-14**], his heart rate was 0 and his vent
was turned off. The family was informed beforehand that
nothing further could really be done for him and withdrawal
of aggressive medical therapy was indicated. They agreed and
the patient expired.
DISCHARGE DIAGNOSES:
1. Closed head injury.
2. Pulmonary contusions.
DISCHARGE STATUS: Deceased.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Last Name (NamePattern4) 43600**]
MEDQUIST36
D: [**2106-11-1**] 15:40
T: [**2106-11-1**] 22:12
JOB#: [**Job Number 43601**]
ICD9 Codes: 0389, 4271 | [
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train_25554 | completed | 022da784-1ddf-457e-8f3c-5ed58eba2d87 | Medical Text: Admission Date: [**2143-7-12**] Discharge Date: [**2143-8-6**]
Date of Birth: [**2074-6-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cough And/Or Cold Preparation Classif
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Aortic and mitral valve stenosis
Major Surgical or Invasive Procedure:
Aortic valve replacement, mitral valve replacement
History of Present Illness:
This 69 year old male with a history of shortness of breath was
investigated and found to have severe aortic stenosis and severe
mitral regurgitation with reasonably preserved left ventricular
function in place of severe regurgitation. The coronary arteries
were normal on angiogram. The medical history was significant
for alcoholic cirrhosis of the liver, class B Childs
classification. After much discussion with the family and the
patient, they wished to proceed with high risk double valve
replacement.
Past Medical History:
Aortic Stenosis
Mitral Regurgitation
Atrial Fibrillation
Congestive Heart Failure
Alcholic cirrhosis, Child's class B
Pulmonary hypertension
Right inguinal hernia repair
Social History:
Quit smoking 5 yrs ago after 60pk/yr/hx.
Quit drinking 18 yrs ago. Reported he was a heavy drinker.
Denies recreational drug use.
Family History:
Non-contributory
Physical Exam:
Temp 97.8 HR 51 BP 109/73 RR 20 SaO2 97% on 6L
Alert, oriented, anxious
Lungs CTAB
Heart RRR
Abd soft, distended
Ext 2+ BLE edema
Pertinent Results:
INR 1.4
T bili 4.7
Creatinine 1.9
Brief Hospital Course:
The patient was admitted to the Cardiac surgery service and
underwent mitral and aortic valve repair on [**2143-7-16**]. The
patient's postoperative course was, as predicted, complicated.
He failed to wean off the ventilator, resulting in an open
tracheostomy procedure on [**2143-7-23**], subsequent DIC, and renal
failure requiring CVVH. His course was further complicated by GI
bleeding, resulting in exploratory laparotomy on [**2143-7-28**],
negative for ischemic colitis. Gastric/jejunostomy feeding tubes
were placed. The patient developed infection with Pseudomonas at
multiple sites. Ultimately, the patient's liver failed.
Transplant surgery was consulted, but there was no hope for
recovery of his liver function, nor was the patient suitable for
a transplant. The family, after several days of deliberation and
discussion with the attending surgeon and housestaff, decided to
withdraw supportive care, and Mr. [**Known lastname **] [**Last Name (Titles) **] on [**2143-8-6**].
Medications on Admission:
Digoxin 0.125, Enalapril 20, Lasix 80, Combivent, Xanax prn
Discharge Medications:
n/a
Discharge Disposition:
[**Date Range **]
Discharge Diagnosis:
Cardiac arrest, multisystem organ failure, liver failure
secondary to alcoholic cirrhosis
Discharge Condition:
[**Date Range **]
Completed by:[**2143-8-6**]
ICD9 Codes: 5185, 0389, 4280, 5789, 5849 | [
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train_26374 | completed | 206a14cb-db8a-495e-a4e0-847378b42340 | Medical Text: Admission Date: [**2131-7-27**] Discharge Date: [**2131-8-3**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Back pain, hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Mrs. [**Known lastname **] is a 26 yo F with DMI
and multiple admissions for DKA who presents with back pain and
hyperglycemia. She has had chronic back pain since an MVA in
[**2124**] that intermittently comes and goes, and for which she
states she takes 'her mother's percocet' but is not prescribed
anything by her PCP. [**Name10 (NameIs) **] noticed worsening onset of her back
pain this morning ([**5-10**], non-radiating, no neurologic deficits,
no saddle anesthesia). She also noticed that her fingersticks
were higher than normal, as she was about 240s without eating,
and then progressed to 'critical high' on her glucometer (at
baseline, she states her FS range from 150s-280s after meals).
Also noticed some increased polyuria over the past 2 days. She
reports taking her insulin as directed, and reports her Lantus
was recently increased from 22->28->30 U QHS by a physician at
[**Name9 (PRE) 22652**] Corner Dr. [**First Name (STitle) 1255**], and her Aspart sliding scale has
remained the same. Has been seen by [**Last Name (un) **] in the past but did
not follow up since 2/[**2130**]. She denies missing any doses. No
localizing infectious symptoms such as fever, chills, chest
pain, SOB, abdominal pain, diarrhea, dysuria, or rash. She
endorses nausea and vomiting only upon admission to the ED, when
she vomited 3 times. Her back pain and her critically high FS
resulted in her presentation to the ED.
.
In the ED, initial vs were: 98.5 139 151/93 16 100% on RA. She
triggered for tachycardia in triage, which was accompanied by
nausea and vomiting. Patient was given Zofran 2 mg IV x2,
Dilaudid 0.5 mg IV x2 for her back pain and promethazine 25 mg
IV x1. Received 3 L of IVFs total, and was receiving NS with 20
mEQ of K on transfer. Labs notable for FS of 726, Cre of 1.3,
Chem-7 slightly hemolyzed with K of 6.2 (4.9 on repeat), Na 132,
initial AG of 21. U/A spilling glucose, +ketones, [**5-10**] RBCs. WBC
of 6.5. Insulin gtt (6 U bolus and 6 U/hr) was started. VS were
98.6 103 127/87 18 100% on RA with FS of 253 prior to transfer,
so insulin gtt was stopped prior to floor transfer.
.
On the floor, patient is walking and talking, but endorses back
pain and states she is hungry and wants to eat. Her nausea and
vomiting have improved. FS was 206. Patient appeared
disinterested in giving history about her diabetes and only
interested in pain medication for her back
Past Medical History:
-Diabetes Type I: diagnosed age 16 in [**2120**] after her first
pregnancy. Most recent Hgb A1C 10.9 % ([**8-9**])
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis on metoclopramide
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-4**] - lower back pain since then. Per patient,
received oxycodone from her primary provider.
[**Name Initial (NameIs) **] [**Name Initial (NameIs) 58252**]
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own apartment near [**University/College 5130**] with her son, who is 8 years
old. Her son is currently staying with her aunt. She has family
nearby who help out. She is planning on going to school to be a
medical assistant. She denies tobacco, alcohol or illicit drug
use.
Family History:
Her grandmother had type II diabetes. No family history of
inflammatory bowel disease.
Physical Exam:
Upon admission:
General: AA female, no acute distress, affect flat and downward
gazing during most of history
[**University/College 4459**]: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +vertical incision well healed with overlying keloid;
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
Neuro: no TTP spinally or paraspinally. CNs [**1-12**] intact. [**4-4**]
strength in upper and lower extremities. 2+ reflexes in
patellar, achilles tendons. sensation grossly intact BL.
cerebellar fxn intact. gait WNL.
Upon discharge:
Vitals: T: 99.6 BP: 156/102 P: 126 R: 20 O2: comfortable on RA
General: Alert, oriented, no acute distress
[**Month/Day (1) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, 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
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
[**2131-7-27**] 08:00PM URINE HOURS-RANDOM
[**2131-7-27**] 08:00PM URINE UCG-NEGATIVE
[**2131-7-27**] 08:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-7-27**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.032
[**2131-7-27**] 08:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2131-7-27**] 08:00PM URINE RBC-[**5-10**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2131-7-27**] 07:34PM GLUCOSE-GREATER TH K+-4.9
[**2131-7-27**] 07:30PM GLUCOSE-753* UREA N-19 CREAT-1.3* SODIUM-132*
POTASSIUM-6.2* CHLORIDE-91* TOTAL CO2-21* ANION GAP-26*
[**2131-7-27**] 07:30PM HCG-<5
[**2131-7-27**] 07:30PM WBC-6.6# RBC-4.24 HGB-12.3 HCT-38.1 MCV-90
MCH-29.0 MCHC-32.2 RDW-14.3
[**2131-7-27**] 07:30PM NEUTS-67.8 LYMPHS-27.9 MONOS-3.2 EOS-0.5
BASOS-0.5
[**2131-7-27**] 07:30PM PLT COUNT-223#
[**7-28**]
FINDINGS: PA and lateral views of the chest demonstrate no focal
consolidation, effusion, or pneumothorax. There is no evidence
of congestive
heart failure. Cardiomediastinal silhouette is normal. Bony
structures are
intact. There is no free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
[**2131-7-28**] 01:03AM BLOOD Type-[**Last Name (un) **] pO2-38* pCO2-49* pH-7.37
calTCO2-29 Base XS-1
[**2131-7-30**] 06:09AM BLOOD TSH-0.48
[**2131-7-31**] 09:52AM BLOOD ALT-15 AST-17 LD(LDH)-200 AlkPhos-69
Amylase-130* TotBili-0.9
[**2131-7-31**] 09:52AM BLOOD Lipase-17
[**2131-8-1**] 03:43AM BLOOD Glucose-262* UreaN-2* Creat-0.7 Na-136
K-3.4 Cl-103 HCO3-23 AnGap-13
[**2131-8-3**] 06:00AM BLOOD WBC-5.8 RBC-3.88* Hgb-11.1* Hct-34.3*
MCV-88 MCH-28.7 MCHC-32.5 RDW-14.8 Plt Ct-204
[**2131-8-3**] 06:00AM BLOOD UreaN-5* Creat-0.8 Na-137 K-3.9 Cl-104
HCO3-23 AnGap-14
[**2131-8-3**] 06:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.6
[**2131-7-30**] 06:09AM BLOOD TSH-0.48
[**2131-8-3**] 06:00AM BLOOD Free T4-PND
Brief Hospital Course:
26 yo female with history of Type 1 DM, chronic back pain
admitted with hyperglycemia likely a repeat episode of DKA.
Multiple admissions for DKA (at least 8 in [**2129**] and 2 since
[**2130**]). Inciting etiologies are unclear as patient states she is
taking her insulin at home and recently had her dose uptitrated
by her PCP, [**Name10 (NameIs) **] medication non-compliance is likely the
main issue (not taking many of the medications she was
discharged on back in [**5-/2131**], lost to f/u with [**Last Name (un) **] since
2/[**2130**]). The patient states that any acute increase in her back
pain triggers DKA. No chest pain or EKG changes to indicate
evidence of MI. She was found to have a UA positive for UTI with
no symptoms, and she was treated with Ciprofloxacin. She was
seen by [**Last Name (un) **] during her stay. They recommended an increased
dose of Lantus at 35 units daily.
Throughout her stay, she had persistent tachycardia and
hypertension during the day that normalized overnight. Etiology
unclear, but may be related to chronic back pain and persistent
anxiety/agitation. Moreover, she has had tachycardia similar to
this during her previous admission. Back pain was unchanged on
exam and related to MVA 6 years prior. No neurological deficit
or signs of infection. Tachycardia responded somewhat to fluid
boluses, anxioltics, and analgesics. She was seen by psychiatry.
Zoloft was restarted when she began tolerating PO intake. A TSH
was normal at 0.48.
Additionally, her course was complicated by nausea and vomiting
of unclear etiology. She was treated with zofran and reglan
prior to meals, which greatly decreased her nausea, vomiting,
and bloating. She reports history of diabetic gastroparesis but
had a normal gastric emptying study in [**11-8**]. She was eating a
normal diet without issue on the final two days of her
admission.
Medications on Admission:
Lantus 30
Novolog 1:14 [**Doctor Last Name **] for every 40 over 140 FSBS
Zoloft 100
Lorazepam
ASA 81
Protonix 40
Reglan occaisionally
MVI
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO q8h prn as
needed for anxiety.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
7. Novolog 100 unit/mL Solution Sig: 1:14 units Subcutaneous
qidachs: 1:14 [**Doctor Last Name **] coverage for every 40 units >140 finger stick.
8. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO qidachs:
Please stop this medication immediately if you notice any signs
of lip smacking, facial abnormalities or facial muscle spasms.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital1 69**]
because of Diabetic Ketoacidosis. You were treated with insulin
aggressively until your sugars and your blood chemistries
returned to [**Location 213**] values. We gave a lot of IV fluids to
rehydrate you as you were severely dehydrated. We restarted
your home insulin regimen, and made sure to pretreat you with
zofran (antinausea) and reglan (for gut motility) before your
meals. You were discharged once you were back on your home
insulin and able to take meals by mouth.
There were no changes made to your medications. The following
medications that you take were on your last discharge summary
however were not continued after this discharge because you
stated that you were no longer taking them:
-zofran
-exetimibe
-trazadone
-thiamine
-aspirin
Please discuss with your primary care physician if you should
continue these medications.
Followup Instructions:
You are scheduled for a follow up appointment with your NP at
[**Last Name (un) **] on [**2131-8-8**] at 8:30AM. If you need to change
this appointment, please call ([**Telephone/Fax (1) 2384**] to reschedule.
Also, you have an appointment with your PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **], [**First Name3 (LF) **]
Address: [**University/College 17629**], [**Location (un) **],[**Numeric Identifier 58270**]
Phone: [**Telephone/Fax (1) 58261**]
Appointment: Tuesday, [**8-21**], 7:45PM
ICD9 Codes: 5990, 2724 | [
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train_26690 | completed | 58dcfc14-0f6e-40cf-b913-139789a79f57 | Medical Text: Admission Date: [**2116-3-20**] Discharge Date: [**2116-4-3**]
Date of Birth: [**2063-5-5**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
male unrestrained driver, ejected and thrown 10 feet from
car, with a right femur fracture and no loss of
consciousness. [**Location (un) 2611**] Coma Scale was 15. Heart rate was
80. Systolic blood pressure was 140.
PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.
3. Coronary artery disease.
4. Past myocardial infarction.
5. Posttraumatic stress disorder.
6. Rheumatoid arthritis.
7. Depression.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient drinks half a gallon of alcohol
per week. He has not smoked since [**2094**].
ALLERGIES: PENICILLIN (results in pruritus). CODEINE
(results in nausea and vomiting).
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed a temperature of 98, his heart rate was
72, his blood pressure was 142/68, his respiratory rate was
22, and his oxygen saturation was 100%.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 52643**]
MEDQUIST36
D: [**2116-4-3**] 08:52
T: [**2116-4-3**] 09:01
JOB#: [**Job Number 52694**]
ICD9 Codes: 4019 | [
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train_28108 | completed | e4b011a5-a00c-4b00-892b-fdedfa87590c | Medical Text: Admission Date: [**2131-10-3**] Discharge Date:
Service:
DR.[**Last Name (STitle) **],[**First Name3 (LF) 4514**] 12-424
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2131-10-29**] 08:32
T: [**2131-10-29**] 08:40
JOB#: [**Job Number **]
1
1
1
R
ICD9 Codes: 4019, 4241 | [
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train_27934 | completed | 36bd652d-84af-4653-b507-ebf22e1bf891 | Medical Text: Admission Date: [**2158-3-20**] Discharge Date: [**2158-3-25**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 81 year-old
female with a history of shortness of breath and fatigue on
exertion since the summer of [**2147**] which has been increasing
over time. The patient complains of dizziness and postural
orthostatic hypotension. The patient denies orthopnea or
paroxysmal nocturnal dyspnea.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
PAST SURGICAL HISTORY:
1. D&C 30 years ago.
2. Tonsillectomy and adenoidectomy in childhood.
MEDICATIONS:
1. Verapamil 120 milligrams po q day.
2. Xipamide 1.25 milligrams [**Hospital1 **].
3. KCL 10 milliequivalents po bid.
4. Lipitor 10 milligrams po q day.
5. Aspirin 325 milligrams po q day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs blood pressure 113/83,
pulse 86. In general this is a well appearing elderly
female. Skin - no rashes, no scars. HEENT - no jaundice.
Pupils are equal, round and reactive to light. Dentures.
Neck - no JVD, no thyromegaly, no lymphadenopathy. Chest -
crackles at bases bilaterally. Heart - S1, S2, grade IV
systolic murmur. Abdomen - soft, nontender. Nondistended.
Poor rectal tone. Extremities - no cyanosis, clubbing or
edema. Varicosities - slight lower extremity varicosities.
Neuro - alert and oriented times 3.
An echocardiogram and SPECT thallium ETT were performed on
[**2157-9-15**]. The echo showed moderate mitral stenosis. The mean
diastolic gradient was 7 mm with mitral valve area of 1 cc
squared, 1.4 cm squared by pressure half time. The mitral
leaflets were thickened and with reduced mobility and
diastolic doming. There is at least 2+ MR with mild aortic
sclerosis and mild TR. There was mild to moderate pulmonary
hypertension. The LA was moderately dilated.
On [**2158-3-20**] the patient was admitted to [**Hospital1 190**] and underwent a mitral valve repair with a #27
Mosaic valve. The patient did well postoperatively and was
transferred to the CSRU.
On postoperative day one the patient's chest tubes were
removed. The patient's Swan Ganz catheter was removed. The
patient was transferred to the floor on postoperative day
one.
On postoperative day two the patient received one unit of
packed red blood cells for a hematocrit of 24. On
postoperative day two the patient was up and ambulating with
physical therapy.
On postoperative day three the patient continued to do well
and was noticed to be in atrial fibrillation, atrial flutter
with a rate of 74. The patient was started on Amiodarone
bolus with Amiodarone 400 milligrams po tid. The patient
then converted to sinus.
On postoperative day four the patient's wires were removed as
the patient has been in sinus rhythm for 24 hours. The
patient was at a level V with physical therapy on
postoperative day four and discharged on postoperative day
five with plan.
DISCHARGE CONDITION: The patient's discharge condition was
good.
DISCHARGE MEDICATIONS: The patient was discharged on the
following medications:
1. Amiodarone 400 milligrams po tid times five days.
Amiodarone 400 milligrams po bid times seven days. Amiodarone
400 milligrams po q day times seven days.
2. Lasix 20 milligrams po bid times seven days.
3. Lopressor 25 milligrams po bid.
4. Percocet 5/325 one to two tablets po q four to six hours
prn dispense #40.
5. Colace 100 milligrams po bid.
6. Lipitor 10 milligrams po q day.
7. Aspirin 325 milligrams po q day.
8. KCL 20 milliequivalents po bid times seven days.
9. Zantac 150 milligrams po bid.
DI[**Last Name (STitle) 408**]E STATUS: The patient was discharged to home with
her family to follow up with Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2158-3-24**] 13:55
T: [**2158-3-24**] 14:05
JOB#: [**Job Number 38560**]
ICD9 Codes: 4240, 9971, 4019, 2720 | [
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train_38397 | completed | ca7dc9aa-75ff-469e-946b-c4384313baee | Medical Text: Admission Date: [**2105-6-30**] Discharge Date: [**2105-7-1**]
Date of Birth: [**2078-11-6**] Sex: M
Service: MEDICINE
Allergies:
clindamycin / vancomycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The patient is a young caucasian male who was found unresponsive
in the Fens by EMS, and who was subsequently intubated in the
field and transferred to [**Hospital1 18**] ED. No other pre-hospital data or
documentation is available.
.
In the ED, initial vs were: T95.9 P69 BP128/76 R14 O2 sat100% on
CMV set at Vt500/R14/PEEP5/Fi021.00. He was placed on
fentanyl/midazolam gtt for sedation. A trauma series was
negative, including a normal FAST panel and a CT head/neck which
were unremarkable for acute fracture. An NGT was placed though
no output retrieved when placed to suction. He was initially
hypothermic to 91F and bearhugger was placed with good effect.
He received 3L NS in the ED and was transferred to the [**Hospital Unit Name 153**].
.
Upon arrival to the [**Hospital Unit Name 153**], his initial VS were T96.4 BP120/73
RR14 P71 Sat100% on Fi0250%. His sedation was lightened and he
was able to interact with staff and nod for questioning. He had
a license identifying him as [**Known firstname 429**] [**Known lastname 1968**], and he was able to
confirm that this is true. He is in no significant pain. Limited
history suggests that he was drinking alcohol last night. He had
a bottle of clear liquid in his personal belongings, though he
does not know was this is.
.
Review of his previous records shows that he presented to the ED
last [**Month (only) 216**] for help with daily use of amphetamine. A psych note
from that time revealed that he was then homeless with a history
of polysubstance abuse, particularly with almost daily
amphetamine use in addition to gamma-hydroxybutyric acid (GHB),
though he had also experimented with cocaine, MDMA, though no
IVDA. He was engaging in sexual activity to fund his drug habit.
.
He has a history of depression and anxiety, though had never
been consistently treated. He a suicide attempt several years
ago in which he overdosed on xanax, drank alcohol to excess, and
took GHB. He had been hospitalized several times for his
depression.
Past Medical History:
- depression
- anxiety
- history of suicide attempt
- polysubstance abuse (particularly methamphetamine, GHB)
- Ventricular septal defect
Social History:
Occupation: Works at [**Company **]
Drugs: clean x6months, polysubstance abuse in past with GHB and
amphetamine
Tobacco: smokes [**1-25**] PPDx5yrs
Alcohol: 5 drinks per setting x2 weekly
Other: Lives with grandmother in [**Name2 (NI) **]
Family History:
father died from cirrhosis, mother died from heroin overdose.
Physical Exam:
Vitals: T95.9 P69 BP128/76 R14 O2 sat100%
Vent: CMV set at Vt500/R14/PEEP5/Fi021.00General: Alert,
oriented, no acute distress
HEENT: pupils are 3mm and reactive bilaterally without
nystagmus. MMM. ETT in place. Cervical collar is in place.
Neck: supple, cervical collar in place
Lungs: Anterior exam clear to auscultation bilaterally, no
wheezes, rales, rhonchi
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, DP, PT pulses could not be palpated
though were present with doppler U/S. several abrasions over
ankles bilaterally.
NEURO: Nodding y/n to questions. Opens eyes and follows
commands. 2+ DTR in [**Name2 (NI) 15219**].
Physical Exam on Day of Discharge
HEENT: pupils are 3mm and reactive bilaterally without
nystagmus. MMM. ETT in place. Cervical collar is in place.
Neck: supple, cervical collar in place
Lungs: Anterior exam clear to auscultation bilaterally, no
wheezes, rales, rhonchi
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, DP, PT pulses could not be palpated
though were present with doppler U/S. several abrasions over
ankles bilaterally.
NEURO: Nodding y/n to questions. Opens eyes and follows
commands. 2+ DTR in [**Name2 (NI) 15219**].
Pertinent Results:
Labs on Admission:
[**2105-6-30**] 08:38AM BLOOD Glucose-123* UreaN-11 Creat-1.0 Na-146*
K-4.0 Cl-107 HCO3-25 AnGap-18
[**2105-6-30**] 08:38AM BLOOD WBC-9.3 RBC-4.99 Hgb-16.0 Hct-46.4 MCV-93
MCH-32.0 MCHC-34.4 RDW-14.1 Plt Ct-197
[**2105-6-30**] 08:38AM BLOOD PT-12.1 PTT-27.0 INR(PT)-1.0
[**2105-6-30**] 08:38AM BLOOD Fibrino-295
[**2105-6-30**] 08:38AM BLOOD Lipase-19
[**2105-6-30**] 08:38AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.0
[**2105-6-30**] 05:40PM BLOOD Osmolal-287
[**2105-6-30**] 08:45AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2105-6-30**] 08:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2105-6-30**] 08:45AM URINE RBC-0 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
[**2105-6-30**] 08:38AM BLOOD ALT-20 AST-23 AlkPhos-54 TotBili-0.4
[**2105-6-30**] 08:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2105-6-30**] 08:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Labs on Discharge:
[**2105-7-1**] 03:49AM BLOOD WBC-9.3 RBC-4.26* Hgb-13.5* Hct-38.6*
MCV-90 MCH-31.7 MCHC-35.0 RDW-13.4 Plt Ct-196
[**2105-7-1**] 03:49AM BLOOD Glucose-111* UreaN-8 Creat-0.9 Na-139
K-3.7 Cl-104 HCO3-29 AnGap-10
[**2105-7-1**] 03:49AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
Brief Hospital Course:
Mr. [**Known firstname 429**] [**Known lastname 1968**] is a 27yoM with a history of polysubstance
abuse, depression, and anxiety who was intubated in the field
for management of altered mental status presumably due to a drug
intoxication. He is transferred to the [**Hospital Unit Name 153**] for further care.
# RESPIRATORY DEPRESSION: Though we lack records of the patients
status in the field, he was intubated for altered mental status
and respiratory protection. The precipitant is unknown, though
he has experimented with numerous CNS depressants in the past
that can suppress normal respiration (GBH, ketamine,
benzodiazepines). Patient was extubated successfully. After
extubation, he endorsed taking EtOH as well as GBH. Upon
discharge, he was alert, awake, oriented without focal deficits
on neurological exam.
# ALTERED MENTAL STATUS: Limited history is available from the
patient initially. He has several scrapes on his lower extremity
though CT head and neck show no obvious fracture or bleed.
Though initial urine and serum tox screens are negative, he has
previously used substances that are not normally identified on
routine screens such as GBH and ketamine. Each of these drugs
have relatively short half lives and should be clearing, which
may explain his improving mental status. After extubation,
patient endorsed drinking EtOH and GBH. His initial prolonged
QTc, likely related to hypothermia, resolved.
# URINARY KETOSIS: Ketones to 40 noted on admission UA, unclear
cause as he is not spilling glucose. Does not appear
malnourished. He was drinking alcohol last night which may have
induced ketosis.
# ACIDEMIA: pH noted to be acidemic at 7.32, though gas is
confusing with normal bicarbonate and pC02. Unclear precipitant
though his clinical improvement is ultimately reassuring.
# H/O POLYSUBSTANCE ABUSE: Long history of drug use. Patient
was evaluated by SW after extubation. He ultimately decided to
seek long term detox program and called [**Hospital 12671**] Hospital, which
did not have a bed for him today. They asked the patient to
call again on [**2105-7-2**] to inquire for a bed. At the same time,
follow up appointment was set up for him to establish care with
a new PCP so that he could be better followed mediaclly.
# DEPRESSION/ANXIETY: Current status is unclear. However, he
will need to have psychiatric evaluation in the outpatient
setting to further address this issue. He currently does not
have a regular psychiatrist but does see a therapist weekly per
patient. Upon discharge, patient reports feeling safe and is
planning to go to his grandmother's house. He is planning to
call [**Hospital 12671**] Hospital again on [**2105-7-2**] to set up follow up/long
term de-tox program.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Intoxication
Secondary diagnoses:
- Polysubstance abuse
- Depression
- Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1968**],
You were admitted after you were found to be unconscious in the
[**Hospital1 778**] area. You were intubated (breathing tube placed) by the
EMS workers in the ambulance. You were able to be extubated once
you woke up in the ICU. You then revealed that you had taken GHB
as well alcohol. You decided that you would need more assitance
with your drinking and using of substances, so you are planning
to attend a more long term program for your current substance
use issue. Currently you feel safe and is planning to return to
your family's home.
You are advised to stop drinking and using illicit drugs,
because persistent use of these substances can lead to death.
Please note that there is NO change in your medications.
It is VERY IMPORTANT for you to follow up with your mental
health provider, [**Name10 (NameIs) 19566**] [**Name Initial (NameIs) **] psychiatrist, as well as
establishing care with a primary care physician.
Followup Instructions:
Thursday, [**2105-7-2**] at 1pm with Dr. [**Last Name (STitle) 71076**].
[**Street Address(2) **]
[**Location (un) 1294**], [**Numeric Identifier 44211**]
Appointment Tel: [**Telephone/Fax (1) 66403**]
You said that you are calling your mental health provider at
[**Name9 (PRE) 12671**] Hospital at [**Telephone/Fax (1) **] today to set up a follow up
appointment so that you can be seen today or tomorrow for your
recent admission to the hospital and to set get set up for the
detox program.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2105-7-1**]
ICD9 Codes: 2762, 3051 | [
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train_35832 | completed | c8f61be3-5123-464d-9ba6-c7af8b9cb23d | Medical Text: Admission Date: [**2104-7-23**] Discharge Date: [**2104-8-1**]
Date of Birth: [**2022-7-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
Emergent coronary artery bypass grafts x 4
(LIMA-Dg,SVG-LAD,SVG-PDA,SVG-PLV) [**2104-7-26**]
Placement of intra-aortic balloon pump [**2104-7-26**]
left heart catheterization, coronary angiogram [**2104-7-23**]
History of Present Illness:
This 82 year old white male is s/p LAD stenting in [**Month (only) 547**] of this
year. He presented to an outside hospital wiht 2 weeks of
intermittent chest pain and dyspnea while walking, relieved with
sublingual Nitroglycerin. He was transferred to [**Hospital1 18**] for
further evaluation.
Past Medical History:
CAD: RCA PCI [**2095**]
LAD PCI 4/ [**2103**]
LAD and Diagonal POBA [**5-/2104**]
Hypertension
Dyslipidemia
TIA (15-20 yrs ago)
Epistaxis (no problems in 3 years)- uses humification
Rectal Cancer
Past Surgical History
s/p bowel resection for rectal cancer
s/p gum surgery for teeth
Social History:
noncontributory
Family History:
Family History: non contributory
Race: Caucasian
Last Dental Exam: 3 months ago
Lives with: spouse
Occupation: retired firefighter
Tobacco: denies
ETOH: 1 glass a month
Physical Exam:
admission:
Pulse: 47 Resp: 12
B/P Right: Left: 97/53
General: no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] anterior
Heart: RRR [x] Irregular [] Murmur none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: alert and oriented x3 nonfocal - unable to assess gait
Pulses:
Femoral Right: cath site Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2104-7-25**] Echo
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function appears normal (LVEF>55%). The aortic valve
leaflets are mildly thickened (?#). Mild (1+) aortic
regurgitation is seen. On either 1:1 or 1:2 IABP setting, the AI
appears similar.
Compared with the prior study (images reviewed) of [**2104-7-24**], no
definite change. IABP may be new.
[**2104-8-1**] 04:25AM BLOOD WBC-5.6 RBC-2.72* Hgb-8.9* Hct-25.5*
MCV-94 MCH-32.6* MCHC-34.9 RDW-14.7 Plt Ct-292
[**2104-7-31**] 09:45AM BLOOD PT-14.1* INR(PT)-1.2*
[**2104-8-1**] 04:25AM BLOOD Glucose-72 UreaN-17 Creat-1.0 Na-137
K-4.1 Cl-104 HCO3-23 AnGap-14
Brief Hospital Course:
Following admission he under went catheterization which
demonstrated diffuse in-stent restenosis, including a 70%
bifurcatrion lesion, 60-70% stenosis of the PDA and marginal
origin of a small right posterolateral vessel. He received
Plavix and was then referred for surgical consideration.
He was transferred to the floor, on no intravenous
anticoagulants or Nitroglycerin. He had several episodes of
angina at rest in the next couple of days and in the early
morning of [**7-25**] had 10/10 chest pain. Cardiac Surgery was
notifed and an intra-aortic balloon was placed by cardiology.
He was stable and painfree then and in the afternoon he was
taken to the Operating Room where revascularization was
performed.
He weaned from bypass in stable condition with the balloon pump
in place. The following morning the balloon was removed, he was
awakened and extubated. 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. He did develop post-op atrial
fibrillation and was treated with amiodarone, titration of beta
blocker and coumadin was initiated for anti-coagulation. He did
experience urinary retention and his foley was re-placed.
Flomax was initiated and following removal of the foley
catheter, the patient did void. Narcotics were discontinued for
post-op confusion. The confusion improved with Haldol and
sleep. The patient was evaluated by the physical therapy
service for assistance with strength and mobility.
By the time of discharge on POD seven the patient was ambulating
freely, the wound was healing, pain was controlled with oral
analgesics, and his confusion resolved. The patient was
discharged in good condition with appropriate follow up
instructions.
Medications on Admission:
ASPRIN Dosage uncertain
CLOPIDOGEL - 75 mg Tablet daily
ISOSORBIDE MONONITRATE - 30 mgBID
LISINOPRIL 10 mg daily
METOPROLOL SUCCINATE 25 mg daily
SIMVASTATIN 20 mg Tablet daily
TAMSULOSIN [FLOMAX] - 0.4 mg daily
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
Disp:*30 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
13. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itchiness.
15. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO TID (3 times a day) as needed for hiccoughs.
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
18. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 400mg daily for 1 week, then decrease to 200mg daily
ongoing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
unstable angina
s/p coronary artery bypass grafts
hyperlipidemia
s/p coronary stents/angioplasties
hypertension
h/o rectal carcinoma
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
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 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**]
**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) 914**] ([**Telephone/Fax (1) 170**]) on Date/Time:[**2104-8-25**] 1:00
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] [**8-29**] at 1pm
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) 47377**] [**Name (STitle) 111423**] ([**Telephone/Fax (1) 17503**]) in [**2-25**] 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:[**2104-8-1**]
ICD9 Codes: 4111, 9971, 2930, 4241, 5859 | [
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train_41348 | completed | b9b6ded1-7039-4428-952c-c3359e28e3e2 | Medical Text: Admission Date: [**2116-11-3**] Discharge Date: [**2116-11-6**]
Date of Birth: [**2045-9-5**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: Patient is a 71 year-old male
with electrocardiogram showing T wave inversions in V5
through V6 on a routine office visit. Patient was
asymptomatic, underwent exercise tolerance test on [**2116-10-30**]. Exercise tolerance test was positive. Patient had
no chest pain at that time but had shortness of breath.
Ejection fraction at that time was 35 percent and
catheterization on [**11-3**] showed left main coronary
artery 40 percent stenosis, dissection, 50 percent distal
occlusion, LAD 80 percent ostial occlusion.
PAST MEDICAL HISTORY: Significant for hypercholesterolemia
and smoking.
PAST SURGICAL HISTORY: Polyp removed two years ago and
appendectomy.
HOME MEDICATIONS: Included Lipitor 20 mg p.o. q.d., aspirin
325 mg p.o. q.d., Atenolol 25 mg p.o. q.d.
HOSPITAL COURSE: Patient underwent coronary artery bypass
graft times two by Dr. [**Last Name (STitle) 70**] on [**2116-11-4**] with
LIMA to LAD and SVG to PDA. Postoperatively patient did
well. In the Intensive Care Unit patient was extubated and
weaned off all drips without incident. On postoperative day
one patient was transferred to the regular floor unit.
Patient was able to ambulate approximately 500 feet with
assistance and climb a flight of stairs prior to discharge.
Upon discharge patient's vital signs were stable, afebrile,
and chest was clear to auscultation bilaterally. Heart was
regular rhythm, normal sinus. Incision clean, dry and
intact, no pus, no drainage. Sternum was stable. Discharge
medications included Lopressor 25 mg p.o. b.i.d., Lasix 20 mg
p.o. q.d. times five days, potassium chloride 20 mEq p.o.
q.d. times five days, aspirin 81 mg p.o. q.d., Lipitor 20 mg
p.o. q.d., Percocet 1 to 2 tabs p.o. q. 4 to 6 hours p.r.n.,
Colace 200 mg p.o. q.d. Patient was told to follow up with
[**Doctor Last Name 70**] in three to four weeks and patient arranged to have
home nursing care for wound check, vital sign monitoring and
physical therapy.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2116-11-6**] 16:47
T: [**2116-11-6**] 17:06
JOB#: [**Job Number 36320**]
ICD9 Codes: 2720 | [
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train_41063 | completed | 16477a25-cd9f-4a05-801f-cb05f178445b | Medical Text: Admission Date: [**2102-5-23**] Discharge Date: [**2102-5-26**]
Date of Birth: [**2047-1-28**] Sex: M
Service: MEDICINE
Allergies:
Bethanechol / Levofloxacin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Muscle spasms
Major Surgical or Invasive Procedure:
Placement of a PICC
History of Present Illness:
Patient is a 55 y.o. male s/p C6 injury ([**2069**]) c/b autonomic
dysreflexia, spasticity, neurogenic bladder with chronic foley
who presented from OSH with increased episodes of autonomic
dysreflexia that included muscle spasms, tachycardia,
hypertension/hypotension in setting of UTI. Patient was
initially admitted to unit for labile BP, including hypotension.
Patient reports recently being treated for UTI at an OSH with
levofloxacin and macrobid. He was discharged home with
macrobid. He endorses increasing episodes of autonomic
dysreflexia over the past few days despite being treated for
ESBL UTI. He presented to OSH yesterday with these symptoms,
and was transferred to [**Hospital1 18**] for further management. The
patient had endorsed chest pain that was not [**3-7**] ACS, and had
CTA chest that was negative for PE.
.
Approximately 8 months ago he began experiencing episodes of
autonomic dysreflexia. The muscle spasms associated with these
episodes are extensor only and begin in his legs and move
proximally to involve his hips, middle and upper back. Each
extensor spasm lasts only a few seconds, is recurrent every few
minutes, and is painful, culminating in discomfort in the left
chest region. Associated with the spasms are: acute onset severe
headaches, blurred vision, mild sweating/hot feeling, and a
feeling of disorientation. Systolic blood pressure (taken at
work and at home) during these episodes is elevated to the
170-200 range. Sitting upright helps reduce the spasms and
symptoms of autonomic dysreflexia.
.
In the ED, initial vs were: 98.7 81 122/64 18 100, though he
also had an episode of hypotension in the 60s. Patient was given
vancomycin for concern for sepsis. Dropped pressures to the
60's. The patient received IVF and had a clonidine patch was
removed. Admitted to MICU for hypotension with ? sepsis.
.
In the MICU, patient continued to complain of spasms. He denied
any dysuria, fevers, or chills. Patient reports foley catheter
was last changed about a week ago. His UTI was positive for P.
Aeruginosa. His antibiotics were changed from zosyn to
meropenem. His foley catheter was changed.
.
On the medicine floor, the patient endorses spasms. He denies
chest pain/SOB. He also denies f/c. He has no abdominal pain.
He is concerned about his urologic care. He had been followed
by a urologist until recently. He had a scheduled urodynamic
eval that he was not able to keep [**3-7**] his recent
hospitalization.
Past Medical History:
(1) Traumatic C6 quadroplegia from car accident in [**2069**]
(2) Neurogenic bladder, has had indwelling foley catheter for
last 10 years.
(3) Dysreflexia - autonomic and somatic
(4) Spasticity
(5) Multiple UTIs (including ESBL E. coli)
Social History:
Lives alone, not married, no children. Smoked, quit 6 mos ago,
2-3 beers/night. Denies illicits. Works at VA in [**Hospital1 1474**].
Family History:
Non-contributory.
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
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. contractures of bilateral hands; external rotation of
bilateral feet.
Exam at discharge: afebrile, 120/80s, HR 90s, 93% RA
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: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. contractures of bilateral hands; external rotation of
bilateral feet.
unchanged exam
Pertinent Results:
Labs on admission:
[**2102-5-23**] 06:20PM URINE RBC-21-50* WBC-[**4-7**] BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2102-5-23**] 06:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2102-5-23**] 06:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035
[**2102-5-23**] 06:20PM PLT COUNT-231
[**2102-5-23**] 06:20PM NEUTS-71.0* LYMPHS-22.8 MONOS-4.8 EOS-1.0
BASOS-0.4
[**2102-5-23**] 06:20PM WBC-10.6# RBC-4.52* HGB-13.5* HCT-38.3*
MCV-85 MCH-29.8 MCHC-35.3* RDW-14.1
[**2102-5-23**] 06:20PM estGFR-Using this
[**2102-5-23**] 06:20PM GLUCOSE-98 UREA N-9 CREAT-0.7 SODIUM-137
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20
[**2102-5-23**] 06:25PM LACTATE-3.9*
IMAGES / STUDIES:
[**2102-5-23**] CXR: UPRIGHT AP VIEW OF THE CHEST: The left PICC has
been removed. The heart size remains top normal. The mediastinal
and hilar contours are unremarkable. The lungs are grossly
clear. No large pleural effusion or pneumothorax is seen. There
are no acute osseous abnormalities. Partially imaged is a
cerclage wire within the cervical spine. IMPRESSION: No acute
cardiopulmonary abnormality.
MICRO:
- [**2102-5-23**] Urine culture - P. aeruginosa see below
- [**2102-5-23**] Blood culture - NGTD
- [**2102-5-23**] MRSA screen - pending
**FINAL REPORT [**2102-5-25**]**
URINE CULTURE (Final [**2102-5-25**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
MRSA screen (-)
[**5-23**], [**5-25**], and [**5-26**] blood cultures pending
UreaN Creat Na K Cl HCO3 AnGap
7 0.6 139 4.0 102 28 13
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.8 4.38* 12.9* 37.5* 86 29.5 34.4 14.1 184
Brief Hospital Course:
55 y.o. male s/p C6 injury ([**2069**]) c/b autonomic dysreflexia,
spasticity, neurogenic bladder with chronic foley who presents
from OSH with increased spasms, tachycardia, hypertension with a
likely UTI found in our ED to be hypotensive.
# Urinary Tract Infection/Neurogenic bladder. Patient likely has
chronic urinary tract infection or incompletely eradicated
urinary tract infection. He does have a recent history of ESBL
E. Coli in the urine. He was initially started on Zosyn as prior
ESBL E. coli was listed as sensitive, but given this is also a
beta-lactam, he was converted to meropenem on the morning
following admission. Urine culture grew pan-sensitive
Pseudomonas. Meropenem was continued, as patient had recent
history of quinolone-resistent Enterococcus UTI and ESBL E. coli
in past few months. He was continued on home medications of
Detrol and imipramine. He was discharged on [**2102-5-26**] to rehab to
complete a 10 day course of meropenem, a PICC was placed prior
to discharge. The patient will see Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] Urology at [**Hospital1 18**]
on [**2102-6-5**] to establish care and for evaluation of his recurrent
UTIs and possible uro-dynamic studies, as he does not have
access to urologic care at home.
# Autonomic Dysreflexia/Spasticity - Symptoms were likely
exacerbated by urinary tract infections causing worsening of
spasticity. Previous exacerbations of autonomic dysreflexia have
improved with treatment of underlying UTI. BPs were monitored
closely and improved to baseline levels on teh morning following
admission. The patient was continued on home doses of
baclofen/diazepam/clonazepam. The patient required nitro paste
twice in the setting of elevated BP, with good effect.
# Depression/Anxiety. The patient was continued on home doses of
imipramine, and sertraline.
# Osteopenia. Likely due to non-weight bearing status, muscular
atrophy, and possible autonomic nervous system changes. The
patient was continued on his home calcium/vitamin D.
# GERD. Patient was continued on his home omeprazole.
# FEN: No IVF, replete electrolytes, heart healthy diet
# Prophylaxis: Subcutaneous heparin, bowel regimen
# Access: peripherals
# Communication: Patient
# Code: Full (discussed with patient)
Medications on Admission:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constip.
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Nitroglycerin 2 % Ointment Sig: [**2-4**] inch Transdermal prn
dysreflexia as needed for SBP >190: Recheck 1 hour after placing
(or earlier if pt lightheaded). Wipe off for BP <150.
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for spacticity: hold for sedation, rr<12
15. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for headache.
16. Clonazepam 1mg Tablet Sig 1.5 tablets PO every eight (8)
hours.
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
13. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for spasticity.
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain/headache.
15. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
17. Nitroglycerin 2 % Ointment Sig: One (1) [**2-4**] inch Transdermal
PRN as needed for SBP>190: Recheck 1 hour after placing
(or earlier if pt lightheaded). Wipe off for BP <150.
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): please continue while at rehab.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: for PICC
management.
20. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous every
six (6) hours for 10 days: course to complete on [**2102-6-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Primary Diagnoses:
Pseudomonas UTI
Autonomic dysreflexia
Secondary Diagnoses:
Depression and anxiety
Osteopenia
GERD
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:
It has been a pleasure to be involved in your care Mr. [**Known lastname 86093**]
while you have been a patient at [**Hospital1 1170**]. You were transferred here from [**Hospital3 **] because
you were having muscle spasms, fast heart rate, and high blood
pressure consistent with previous episodes of autonomic
dysreflexia. In our emergency department you had low blood
pressure and were admitted first to the ICU and then to the
general medicine [**Hospital1 **]. You were found to have a urinary tract
infection with a bacteria called pseudomonas aeruginosa. We
think that the UTI probably exacerbated your autonomic
dysreflexia. We treated your infection with an antibiotic called
meropenem and you got better. We made plans for you to continue
your treatment in a rehab center and to follow-up with a
urologist as an outpatient.
Please note that the following medications have changed:
-Meropenem
-No other changes were made to your medications.
Please see below for your follow up appointments.
Followup Instructions:
Please follow-up with the following:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2102-6-5**] at 1 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5990, 4589 | [
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train_41168 | completed | 850f023c-4d1a-4efe-8126-0d41637adef1 | Medical Text: Admission Date: [**2148-10-6**] Discharge Date: [**2148-10-18**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
"headache, confusion"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 89 year old woman who lives at home alone. She is a
poor historian but able to tell me that she has been recently
confused with increasing headache level [**7-27**]. She states that
her headache is frontal across the brows. She denies recent
falls, loss of consiousness, nausea, vomiting, weakness,
numbness or tingling sensation, bowel or bladder incontinence.
She
ambulates independently at home without cane or walker. She
reported that her son was concerned about her blood pressure and
brought her to [**First Name4 (NamePattern1) 86990**] [**Last Name (NamePattern1) 3549**] hospital in [**Location (un) 1110**]. CT imaging
showed a right frontal hemorrhage and she was transfered to
[**Hospital1 18**].
Past Medical History:
hypertension, increased cholesterol, chronic low back pain,
arthritis, skin CA removed on left face and over abdomen
Social History:
lives at home alone
Family History:
3 sisters with breast CA
Physical Exam:
PHYSICAL EXAM:On Admission
O: T: 97.2 BP: 140/72 HR:67 R:16 O2Sats: 92%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5-2mm EOMs:intact
Abd: Soft, NT.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam but slow,
normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-19**] 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, 2.5 to 2
mm bilaterally.
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 [**5-22**] throughout. No pronator drift
Sensation: Intact to light touch except L5 decreased bilat,
propioception, pinprick and vibration bilaterally.
Toes downgoing bilaterally
Coordination: finger-nose-finger slower on left, rapid
alternating movements, heel to shin slightly slower on left
CT [**2148-10-6**]:right frontal CVA verses hemorhage with 7 mm midline
shift. Will need MRI with and without contrast to evaluate for
underlying lesion.
Labs:PT 11.7, PTT 24.2, INR 1.0, plat 152, NA 141, K 4.9
Exam on Discharge:
A&O x 0
PERRLA
Not following commands
Moves all extremities x 4
Pertinent Results:
ADMISSION LABS:
[**2148-10-6**] 07:30PM PT-11.7 PTT-24.2 INR(PT)-1.0
[**2148-10-6**] 07:30PM PLT COUNT-152
[**2148-10-6**] 07:30PM NEUTS-74.5* LYMPHS-17.0* MONOS-5.2 EOS-2.5
BASOS-0.8
[**2148-10-6**] 07:30PM WBC-7.4 RBC-3.57* HGB-11.7* HCT-33.5* MCV-94
MCH-32.7* MCHC-34.9 RDW-12.9
[**2148-10-6**] 07:30PM GLUCOSE-95 UREA N-39* CREAT-1.3* SODIUM-141
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15
DISCHARGE LABS:
[**2148-10-16**] 09:00AM BLOOD WBC-9.8 RBC-3.20* Hgb-10.3* Hct-30.5*
MCV-96 MCH-32.2* MCHC-33.7 RDW-13.5 Plt Ct-173
[**2148-10-12**] 03:33AM BLOOD Neuts-92.7* Lymphs-5.0* Monos-2.0 Eos-0.1
Baso-0.3
[**2148-10-16**] 09:00AM BLOOD Glucose-78 UreaN-12 Creat-0.7 Na-139
K-4.2 Cl-110* HCO3-17* AnGap-16
IMAGING:
CT [**2148-10-6**] from OSH :right frontal CVA verses hemorhage with 7
mm midline
shift. Will need MRI with and without contrast to evaluate for
underlying lesion.
MRI head [**10-7**]
1. Dominant cystic-necrotic mass, largely replacing the right
frontal lobe
with predominantly cystic and acute hemorrhagic components,
involving the
rostrum and crossing the midline to involve the left forceps
minor. The lesion extends superficially with evidence of pial
transgression and probable pachymeningeal involvement.
Subependymal involvement cannot be excluded, as the lesion
effaces the right lateral ventricular frontal [**Doctor Last Name 534**]. The overall
appearance favors high-grade primary neoplasm, likely
glioblastoma multiforme.
2. Small necrotic "satellite" lesion in the right precentral
gyrus, consistent with above.
3. Subfalcine herniation, with 12mm leftward shift of midline
structures, but no evidence of uncal or more central herniation.
4. Three punctate acute infarcts in the territory of the distal
A2 and A3
segments of the right ACA, as a consequence of extrinsic mass
effect and
compression of the neighbouring vessels by the right frontal
mass. No evidence of vascular territorial infarction.
VIDEO SWALLOW [**10-16**]:
Limited examination as described above. Aspiration with
nectar-consistency barium.
Brief Hospital Course:
[**10-6**] Pt admitted to neurosurgery service to the ICU on this day
for continued blood pressure control and q1 neurochecks. She did
well on this day and plan was for MRI with and without contrast
for further evaluation of this R frontal mass. Neurology was
consulted for further recommendations and they agreed with plan
for MRI head with and without contrast and blood pressure
parameters of 100-140 systolic. She was started on dilantin
100mg every 8 hours for seizure prophylaxis and plan was to
check a level [**10-7**] a.m .
[**2059-10-7**] Pt neurological exam remained unchanged. MRI on this day
showed R frontal enhancing mass suspicious for glioma. Dilantin
level was 9.6 and she received no bolus. She was neurologically
stable. She was transferred to the floor on 9.22. Surgery was
discussed with the patient and her family. Neurologic oncology
was consulted and had a long discussion with the family and the
patient.
On [**10-10**] pt and her family were seen by the neuro-oncology team
on this day to discuss further treatment options. The results of
this discussion were to forego any agressive care including
surgery and radiation.
ON [**10-11**] pt was found to be more lethargic on exam. She was
opening eyes to voice and following intermittent commands. She
did appear to be somewhat congested and a chest x ray was
obtained for evaluation. Her chest x ray showed a RLL
consolidation and she was started on triple antibiotic therapy
for hospital aquired pneumonia. Speech and swallow evaluated her
and found her unsafe for any PO diet and felt she had been
aspirating her own secretions.She was made NPO and IV fluids
were started. The family wished to continue [**Hospital 17073**] medical
management of her pneumonia throughout the weekend and
re-evaluate her status on Monday [**10-14**] with the possibility of
CMO if she did not improve.
[**Date range (1) **] She remained on IV antibiotics and IV fluids
throughout the weekend and her exam remained stable. Palliative
care was consulted and the plan was for a family meeting on [**10-14**]
to discuss further care options.
[**10-14**] A family discussion with palliative care and the
neurosurgery team took place on this day. The final plan was to
continue [**Hospital 17073**] medical management of her pneumonia and
discharge to home with and bridge from home VNA to hospice care.
[**10-15**] Patient was switched from IV abx to PO levofloxacin and
will continue antibotics for a total of 10 days. Her exam was
improved on this day. SHe was AOx3, more awake and following
commands. Speech and swallow re-evaluated her and cleared her
for pureed diet with nectar thick liquids.
[**Date range (1) 80149**] Pt found to be more lethargic on exam and oriented
only to self. She was unable to take a PO diet or her PO
medications and she was made NPO with IV fluids and her PO
medications were held. Pt was changed to IV antibiotics and will
continue these for a total of 3 more days. Her last dose of IV
antibiotics for treatment of her pneumonia will be on [**10-18**].
After her final IV dose of antibiotics she will be discharged to
home with hospice care.
Medications on Admission:
lasix 40 mg po qd, lopressor 25 mg
[**1-20**] tablet [**Hospital1 **], lisinopril 20 mg [**Hospital1 **], niaspan 750 qd, aspirin 81
mg qd, calcium +d 1 po qd, fish oil 1200 mg [**Hospital1 **], timolo right
eye
q hs
Discharge Medications:
.
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
Disp:*1 drops* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 .* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Until
Dexamethasone is done.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q 72 HOURS ().
Disp:*2160 Patch 72 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Right Frontal Hemorrhage
Right Frontal Tumor
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
GENERAL INSTRUCTIONS
?????? Do not lift objects over 10 pounds until approved by your
physician.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? 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**].
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] as needed. No routine appointments are required.
Completed by:[**2148-10-18**]
ICD9 Codes: 486, 2767, 4019, 2720 | [
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train_41631 | completed | 5a0decfc-6b31-4950-8ef8-f712a2b16c7a | Medical Text: Admission Date: [**2114-9-20**] Discharge Date: [**2114-10-2**]
Date of Birth: Sex:
Service:
ADDENDUM:
PAST MEDICAL HISTORY: Significant for childhood asthma not
requiring current treatment.
MEDICATIONS ON ADMISSION: The patient takes no medications.
Only recreational Heroin, Klonopin, and Oxycontin. The
patient denied any intravenous drug abuse with occasional
social alcohol.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives with parents and is
currently unemployed.
ADMISSION ADDENDUM: The patient's serum toxicology was
negative. Urine toxicology was positive for benzodiazepines,
opiates and negative for Cocaine.
DISCHARGE DIAGNOSIS:
1. Substance abuse.
2. Aspiration pneumonia.
3. Sinusitis.
4. Cardiac injury of unknown etiology.
5. Diffuse lung injury of unknown etiology.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2114-10-1**] 18:51
T: [**2114-10-1**] 20:32
JOB#: [**Job Number 42856**]
ICD9 Codes: 5070, 2851, 5180 | [
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train_39601 | completed | 42a9d8ea-7b95-443a-9e68-bd76dedf8930 | Medical Text: Admission Date: [**2101-11-22**] Discharge Date: [**2101-11-28**]
Date of Birth: [**2024-12-13**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
woman, well known to the neurosurgery service with a subdural
hematoma had a small
subdural hematoma. She was admitted for ten days of
observation and was discharged to rehabilitation.
The patient then developed an increase in the subdural
hematoma, with mental status changes and headache, and was
readmitted and drained in the Operating Room on [**2101-11-18**] and was discharged to rehabilitation. After three days,
she was readmitted now with a decrease in mental status
again, decreased motor skills and decreased communication.
She was unable to answer "yes" or "no" questions.
PAST MEDICAL HISTORY: 1. As above. 2. Hypertension.
ALLERGIES: Erythromycin and penicillin.
MEDICATIONS ON ADMISSION: Percocet, Protonix, Captopril,
hydrochlorothiazide and verapamil.
PHYSICAL EXAMINATION: On physical examination, the patient
was afebrile with a heart rate of 76, blood pressure 168/70,
respiratory rate 14 and oxygen saturation 93%. The patient
was awake and alert, answering questions but slow to respond,
with some weakness on the right side.
HOSPITAL COURSE: The patient had a bedside drainage of the
subdural hematoma via th e frontal burr hole without
complication. This subdural drain
stayed in for two days. On [**2101-11-24**], she had a
repeat head CT scan which showed complete evacuation of the
subdural hematoma.
The drain was discontinued and the patient was transferred to
the regular floor. She was awake, alert and oriented times
three, mobile, extremities with good strength and no drift.
She was seen by physical and occupational therapy and found
to be safe for discharge to home.
DISCHARGE MEDICATIONS:
Verapamil SR 240 mg p.o.q.d.
Hydrochlorothiazide 25 mg p.o.q.d.
Lipitor 10 mg p.o.q.d.
Percocet 5 mg one to two tablets p.o.q.4h.p.r.n.
Colace 100 mg p.o.b.i.d.
CONDITION ON DISCHARGE: Stable.
FOLLOW-UP PLANS: The patient was instructed to follow up
with Dr. [**First Name (STitle) **] in one month with a repeat head CT scan.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2101-11-28**] 11:13
T: [**2101-11-28**] 11:37
JOB#: [**Job Number 16842**]
ICD9 Codes: 5990, 4019, 2720 | [
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train_38042 | completed | b371739a-86ca-42e6-b780-c34ce006dc20 | Medical Text: Admission Date: [**2136-4-12**] Discharge Date: [**2136-4-24**]
Date of Birth: [**2090-9-11**] Sex: M
Service: Plastic Surgery
ADMISSION DIAGNOSIS: Right hand crushing injury.
SECONDARY DIAGNOSES: Tobacco abuse.
CHIEF COMPLAINT: Right hand injury.
HISTORY OF PRESENT ILLNESS: Forty-five-year-old left-hand
dominant male without significant past medical history
suffered a crush injury to right hand at approximately 16:15
on the day of admission. Patient was at a construction site,
where he was working and a hydraulic press crushed his hand.
No other injuries and no significant bleeding seen at an
outside hospital, where the wound was dressed, and the
patient was given Ancef and tetanus. No history of heart
disease or diabetes. Positive two pack per day smoking
history for many years, last p.o. approximately 1 p.m. on day
of admission.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
SOCIAL HISTORY: Two-packs per day of cigarettes for many
years. Social alcohol.
PHYSICAL EXAM: Patient was afebrile with stable vital signs,
alert and oriented in no apparent distress. Clear to
auscultation bilaterally. Soft abdomen. Regular rate and
rhythm. Right upper extremity: Hand is dressed in sterile
gauze. He has an oblique dorsal laceration from mid palm to
the second metacarpophalangeal. There is exposed tendon. On
the dorsal aspect, there is a significant degloving injury
involving much of the dorsal aspect of his hand. There is a
positive volar laceration with exposed tendon and nerves and
vessels at the thenar crease, exposed second
metacarpophalangeal joint, exposed fracture at the head and
the neck of the second metacarpal. The digital nerves and
vessels to the ulnar aspect of the thumb were visualized, no
damage seen grossly. On the radial aspect of the thumb, the
digital nerves and not visualized. Positive nerve and vessel
damage to the ulnar and volar aspect of the second finger or
index finger. The ulnar digital arteries and nerves were
interrupted and the radial nerves and arteries appeared to
have undergone shear forces. Fingers: The middle, ring, and
little fingers exhibit normal motor and sensory function.
The thumb shows positive EPL function held in slight flexion,
weak opponent function. Capillary refill of the thumb was
less than two seconds. Positive light touch on radial and
ulnar aspects. The index finger inconsistent sensory
examination. No capillary refill, no movement, dusky in
appearance.
X-RAYS: A-P, lateral, and oblique of the right hand shows a
comminuted base of the first metacarpal fracture and a
comminuted head of the second metacarpal fracture. No other
fractures visualized.
Chest x-ray was within normal limits.
LABORATORIES: White count 14.6, hematocrit 44.2, platelets
241. Chemistry was 137/4.7/103/26/18/0.8/109. Coags were
12.1/22.1/1.0.
EKG was within normal limits.
BRIEF HOSPITAL COURSE: In the Emergency Room, the patient
was given 15 cc of 1% lidocaine and 0.25% Sensorcaine without
Epinephrine at the radial, median, and ulnar nerve sites in
order to provide wrist block. Prior to physical exam,
wounds are irrigated with 1 liter of sterile normal saline
and above examination was performed.
In the Emergency Room, the patient's second digit, index
finger of the right hand was amputated. The wound was
dressed in a sterile fashion with one stitch placed. That
evening called late at night regarding the thumb being
somewhat dusky and cold without capillary refill and patient
was seen and examined. The splint was loosened. Capillary
refill improved. Color improved. Temperature improved and
patient was seen and examined with Dr. [**Last Name (STitle) 55134**] Poled, and it was
determined that the thumb at that point was viable.
On [**2136-4-13**], patient underwent debridement of the right hand
and open reduction, internal fixation of the right first
metacarpal and also underwent vein graft to that thumb and
during the operation, the thumb appeared to be somewhat
dusky. Postoperatively, the patient was stable. He was
continued on Ancef and levo, which was started in the
Emergency Room.
The patient was sent to the ICU in stable condition. This is
done in order to monitor the thumb q.1h. The thumb remained
with good capillary refill. He then went back to the
operating room for irrigation and debridement of the wound
and completion of amputation.
Patient remained afebrile and stable. Postoperatively, he
was kept on levo and Ancef. Remained in the SICU.
Postoperatively, patient's pain was well controlled with a
PCA. He had a VAC dressing placed on the open wound on the
dorsum of his right hand. Patient was found smoking on
multiple occasions in the bathroom against the hospital
policy and against the advice of the team. This is discussed
significantly with him that this endangers his thumb, the
revascularization procedure performed to his thumb. The
patient then gave his cigarettes to the nursing staff and did
not smoke to our knowledge for the rest of the admission.
After the VAC was placed, the patient was sent to the floor
and remained on antibiotics for the next few days. He was
then taken back to the operating room for skin graft
placement on [**2136-4-19**], and VAC placements again along with
I&D of the wound. Patient postoperatively was sent to the
floor. He did well. He remained on antibiotics, Ancef and
levo. Pain was well controlled postoperatively. Patient's
VAC was then removed on day of discharge. The skin appeared
to have 100% take. Capillary refill of his thumb remained
intact. It was determined that the patient will be
discharged to home with sterile dressing changes, Xeroform
dressing changes to the skin graft site q.d. by home on
nursing, and he will remain on antibiotics.
DISCHARGE INSTRUCTIONS: Patient should follow up with
Plastic Surgery in one week. He will remain on antibiotics
for the next week, Ancef and levo, and he will go home on
Percocet for pain control. He will call if he develops any
fevers or any changes in his wound.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Last Name (NamePattern1) 43342**]
MEDQUIST36
D: [**2136-4-24**] 15:54
T: [**2136-4-25**] 08:47
JOB#: [**Job Number 55135**]
ICD9 Codes: 3051 | [
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train_42164 | completed | f2c46135-19f6-43b5-8ea2-933532f51357 | Medical Text: Admission Date: [**2169-11-14**] Discharge Date: [**2169-11-24**]
Date of Birth: [**2102-6-3**] Sex: M
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 67-year-old
man with a history of ventricular tachycardia, status post
ICD placement, hypertension, hypercholesterolemia, who
sustained head trauma in a motor vehicle accident in [**2169-7-28**] and had a resultant right-sided subdural hematoma.
His hematoma was initially followed by observation. However,
he subsequently developed a left-sided hematoma.
Approximately one week prior to this admission, he had a
right-sided craniotomy and was discharged from that procedure
on [**2169-11-10**]. Over the next few days preceding this
admission, he began to notice some numbness in his left hand
and his family subsequently noticed a left-sided facial
droop. He also noted that he was more clumsy and was
dropping objects when trying to use his left arm and he was
brought into the hospital by his family on [**2169-11-14**]
when they noted an increasing facial droop, slurred speech,
and drooling out of the left side of his mouth.
PAST MEDICAL HISTORY:
1. Atrial fibrillation.
2. Ventricular tachycardia, status post AICD placement.
3. Hypertension.
4. COPD.
5. Systolic congestive heart failure with an ejection
fraction of 25%.
6. Dilated cardiomyopathy.
7. Hypercholesterolemia.
ALLERGIES: Penicillin.
ADMISSION MEDICATIONS:
1. Amiodarone 200 mg once daily.
2. Lipitor 10 mg once daily.
3. Spironolactone 12.5 mg once daily.
4. Lasix 40 mg alternating with 20 mg p.o. q.o.d.
5. Carvedilol 6.25 mg p.o. b.i.d.
6. Flomax 0.4 mg p.o. q.d.
7. Diovan 80 mg p.o. q.d.
8. Multivitamin.
9. Colace.
10. Aspirin 81 mg daily.
SOCIAL HISTORY: The patient is a former smoker, quit 25
years ago, rare alcohol use. The patient is a retired
painter.
FAMILY HISTORY: The patient's mother had a myocardial
infarction at age 74. The patient's father had lung cancer
at age 84.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.3, heart rate 110, blood pressure 115/70, respiratory rate
20, oxygen saturation 98% on room air. General: The patient
was in no acute distress. HEENT: The pupils were equal,
round, and reactive to light. Anicteric sclerae. Supple
neck. Moist mucosal membranes. The extraocular muscles were
intact. Slight droop of the right eyelid and corner of the
right mouth. There was 2-3 cm of JVD. Cardiovascular:
Irregularly/irregular, tachycardia, faint systolic ejection
murmur at the left lower sternal border, radiating to the
apex. Lungs: Crackles at the bases, otherwise clear to
auscultation. Abdomen: Soft, nontender, nondistended,
obese. Extremities: Trace to 1+ peripheral edema.
Neurologic: Cranial nerves II through XII intact
bilaterally, strength 5/5 in all four extremities proximally
and distally, normal gait. No finger-to-nose dysmetria.
Negative Romberg sign. Biceps and quadriceps reflexes 2+
bilaterally.
LABORATORY/RADIOLOGIC DATA: White blood cell count 9.8,
hematocrit 35.6, platelets 388,000. INR 1.2, PTT 29.2,
sodium 141, potassium 3.9, BUN 13, creatinine 1.0, glucose
106, calcium 8.7, magnesium 1.9.
The EKG showed atrial fibrillation with rapid ventricular
response, right bundle branch block, left axis deviation.
EEG showed mildly abnormal EEG due to bifrontal slowing and
then frequent right hemisphere or left frontal slowing
suggesting multifocal subcortical abnormalities. However,
there were no areas of persistent slowing and no epileptiform
features.
Carotid studies showed minimal plaques with bilateral less
than 40% carotid stenosis.
Serial CAT scans of the head revealed stable appearance of
the right subdural hematoma and right frontal craniotomy.
HOSPITAL COURSE: 1. LEFT FACIAL DROOP AND WEAKNESS: The
patient was admitted to the Neurosurgical Service and
Neurology consult was obtained. It was felt that the
patient's symptoms were likely due to local irritation from
the subdural hematoma and much less likely to be due to
stroke. However, the patient subsequently underwent several
echocardiograms. Transesophageal echocardiogram revealed a
definite thrombus in the left atrial appendage along with
dilated right atrium and severe global left ventricular
hypokinesis. Therefore, it was felt that the patient's
symptoms may be due to TIAs resulting from small emboli from
his left atrial thrombus.
The patient was transferred to the Medicine Service and seen
by Cardiology in consultation. It was felt that the patient
will require anticoagulation for this left atrial thrombus in
preparation for eventual cardioversion. However, due to his
recent subdural hematomas and craniotomy there was concern
that anticoagulation with an INR of [**1-30**] result in a
recrudescence of his subdural hematoma. After multiple
serial CAT scans, the Neurosurgical Service thought that it
was safe to anticoagulate the patient to a goal INR of 1.5 to
1.8 with the hopes of increasing that INR goal to 2.0 within
two to three weeks if the subdural hematomas remain stable on
serial CAT scans.
The patient was started on Coumadin on the day of discharge.
His Coumadin dose was 4 mg and his INR was 1.4. He will take
4 mg of Coumadin on [**2169-11-25**] and 3 mg of Coumadin on
[**2169-11-26**] and will have his INR checked on Monday,
[**2169-11-27**] and have this result called into his
cardiologist, Dr. [**Last Name (STitle) **], who will adjust his Coumadin dose.
2. ATRIAL FIBRILLATION: The patient on admission was in
atrial fibrillation with a rapid ventricular response with a
heart rate ranging from 90s to 150s. The patient had low
systolic blood pressures with his rapid ventricular rate with
systolic blood pressures in the mid 80s to mid 90s. An
attempt was made to medically control his rapid ventricular
rate; however, the patient did not respond to increased
Amiodarone, digoxin, and increased beta blockers. Therefore,
the Electrophysiology Service was consulted and the patient
underwent an AV junction ablation and his ICD was
reprogrammed to DDD. His digoxin was discontinued. He was
continued on his daily Amiodarone dose of 200 mg and he was
switched from Lopressor to Carvedilol 3.125 mg p.o. b.i.d.
The patient will follow-up with Dr. [**Last Name (STitle) 73**] in the Device
Clinic.
3. CONGESTIVE HEART FAILURE: The patient was maintained on
a beta blocker, statin, spironolactone, Lasix, and an
angiotensin receptor blocker. He was instructed to weight
himself daily and to call his primary care physician if his
weight increased by more than 5 pounds as he would likely
need extra Lasix doses. He also was instructed to maintain a
2 gram sodium diet and to try to restrict his fluid intake to
1.5 to 2 liters per day.
4. ASPIRATION PNEUMONIA: During the hospital stay, the
patient developed a mildly productive cough with right-sided
pleuritic chest pain and was found to have a right lower
lobe aspiration pneumonia on his chest x-ray. He was started
on a seven day course of Levaquin and Clindamycin which he
will complete as an outpatient.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with follow-up.
DISCHARGE INSTRUCTIONS: Please have your INR checked on
Monday, [**2169-11-27**], and have the results called in to
Dr. [**Last Name (STitle) **] as he will need to adjust your Coumadin dose to
keep your INR at around 1.8. Please follow-up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 73**], telephone number [**Telephone/Fax (1) 902**]. Please follow-up
with Dr. [**Last Name (STitle) **], [**0-0-**], within one week of discharge.
DISCHARGE DIAGNOSIS:
1. Subdural hematoma.
2. Left atrial thrombus.
3. Atrial fibrillation with rapid ventricular response.
4. Aspiration pneumonia.
5. Congestive heart failure with an ejection fraction of
25%.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg daily.
2. Lasix 20 mg alternating with 40 mg every other day.
3. Amiodarone 200 mg q.d.
4. Valsartan 40 mg p.o. daily.
5. Coumadin 4 mg on [**2169-11-25**] and 3 mg on [**2169-11-26**], have your INR checked on [**2169-11-27**] and have
your dose adjusted by Dr. [**Last Name (STitle) **] on that day.
6. Aspirin 81 mg daily.
7. Carvedilol 3.125 mg p.o. b.i.d.
8. Clindamycin 450 mg p.o. q.i.d. for five days.
9. Levofloxacin 500 mg p.o. q.d. for five days.
10. Spironolactone 12.5 mg p.o. daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], M.D. [**MD Number(1) 18174**]
Dictated By:[**Last Name (NamePattern1) 9609**]
MEDQUIST36
D: [**2169-11-24**] 02:49
T: [**2169-11-25**] 18:34
JOB#: [**Job Number 102460**]
ICD9 Codes: 5070, 4254, 4280, 496 | [
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Subsets and Splits