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train_41805 | completed | 0a65841a-358f-49ae-9847-d92aa425f5bf | Medical Text: Admission Date: [**2185-9-8**] Discharge Date: [**2185-9-9**]
Date of Birth: [**2126-9-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
shortness of breath with exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 91176**] is a 58yo female with an unremarkable PMH who
presents with one week of fatigue and dyspnea on exertion. Pt
noted about 1-2 weeks ago increased dyspnea while walking up
hills, flights of stairs, and far distances. Normally, quite
active and healthy at baseline. Pt occasionally gets a bit
dizzy/unbalanced after walking several blocks, having to stop
and catch her breath more often. Pt decided to see her PCP who
did an EKG revealing sinus tachycardia at 103 so pt was sent to
ER for further w/u. Pt states she has lost about five pounds
over the past several weeks, had decreased appetite, decreased
energy, and increased fatigue having to take more frequent naps
which pt attributes to the recent heat. Pt denies any exertional
chest pain, increased cough, pleuritic chest pain, syncope,
recent confusion, back/joint pain, increased thirst, or change
in urination. Pt did experience some vague burning chest pain
across the top of her chest while walking to her PCP's office
today.
.
In the ED, initial vitals HR90 BP109/71 RR16 100% RA. Exam
notable for lungs CTAB. Labs notable for WBC 13.0 with 84% N
and no bands. The pt had a CXR which demonstrated left upper
lobe collapse, and subsequent CT chest w/contrast showed an
approximate 4.6cm LUL mass causing complete collapse of the LUL,
and concerning for primary lung cancer. The patient was admitted
for further evaluation and work-up of lung mass. Pt received 1L
IVF. Vitals prior to transfer 97.0, 72, 102/68, 16, 100% RA.
.
Currently, patient without complaints. Has been ambulating
since arrival to floor, and overall feels dyspnea has been
improving over the last few days. She is hungry and anxious to
get the work-up done so she can go home.
.
ROS: Denies fever, chills, night sweats, headache, shortness of
breath at rest, abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria, peripheral edema, occupational exposures,
recent travel.
Past Medical History:
None
Social History:
Lives alone in [**Location (un) 86**]. Never married, no children. Works as a
genealogist and with the Ford [**Doctor Last Name **] forum. Previously smoked 10
cigarettes/day for 20 years, quit one year ago. Has occasional
drink with dinner. Denies illicits.
Family History:
Father with EtOH abuse and peripheral neuropathy, died at 80.
Mother with HL, died at 88. Brother with a stent. Sister s/p hip
replacement. Denies any family history of cancer.
Physical Exam:
On Admission:
VS - Temp F 98.6, BP114/75 , HR67 , RR16 , O2-sat98 % RA
GENERAL - pleasant thin woman in NAD, comfortable, appropriate,
able to speak in full sentences
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - no JVD, no carotid bruits
LUNGS - decreased BS over left apex, otherwise CTA bilat over
the posterior lung fields, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical or axillary LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-2**] throughout though with possibly 4/5 strength in the LUE on
abduction
.
On Discharge:
V/S: T99.1 BP118/70 HR72 RR18 O296%RA
GENERAL - pleasant thin woman in NAD, comfortable, appropriate,
able to speak in full sentences
LUNGS - CTA bilat over the posterior and anterior lung fields,
no r/rh/wh, good air movement, resp unlabored, no accessory
muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3
Pertinent Results:
LABS
[**2185-9-8**] 01:00PM BLOOD WBC-13.0* RBC-4.34 Hgb-13.3 Hct-38.7
MCV-89 MCH-30.6 MCHC-34.2 RDW-12.0 Plt Ct-583*
[**2185-9-8**] 01:00PM BLOOD Neuts-84* Bands-0 Lymphs-9* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2185-9-9**] 08:10AM BLOOD WBC-7.7 RBC-4.05* Hgb-12.1 Hct-36.5
MCV-90 MCH-30.0 MCHC-33.2 RDW-12.1 Plt Ct-512*
[**2185-9-9**] 08:10AM BLOOD PT-14.0* PTT-30.0 INR(PT)-1.2*
[**2185-9-8**] 01:00PM BLOOD Glucose-111* UreaN-10 Creat-0.6 Na-137
K-3.9 Cl-100 HCO3-25 AnGap-16
[**2185-9-9**] 08:10AM BLOOD ALT-7 AST-9 AlkPhos-87 TotBili-0.3
[**2185-9-8**] 01:00PM BLOOD Calcium-9.1 Phos-2.8 Mg-2.1
.
IMAGING
CXR: Left upper lobe collapse. Recommend CT evaluation to assess
for
obstructing lesion.
.
CT Chest:
1. Mass in the left upper lobe measuring up to 4.6 cm, causing
complete
collapse of the left upper lobe, most consistent with a primary
lung
malignancy. This tumor is centrally located and extends into the
mediastinal fat. It encases the left pulmonary artery and
severely narrows it causing relative oligemia of the left lower
lobe when compared to the right lung. No mediastinal or hilar
lymphadenopathy.
2. Left lower lobe pulmonary nodule measuring 6 mm x 3mm and
right lower lobe nodule measuring 2 mm.
3. Nodularity of the left adrenal gland measuring up to 9 mm,
incompletely
assessed on this single phase study.
Brief Hospital Course:
Pt is a 58yoF, former smoker with no other significant PMH here
with DOE for the past week and new mass on CXR/Chest CT
concerning for primary lung cancer leading to left upper lobe
collapse.
.
# Lung Mass: Likely cancer given pt's smoking history.
Infectious causes less likely given pt's negative history of
exposures or recent travel. Pt is asymptomatic aside from mild
DOE, satting well on room air and while ambulating, however
location and size of mass is concerning. Pulmonary consult was
obtained who felt that no urgent intervention was needed at this
time. Interventional Pulmonology was consulted who initially
felt that a CT-guided biopsy of the mass by Interventional
Radiology was preferred so that was arranged for patient as an
outpatient. After discharge, IP decided that the mass could be
biopsied via outpatient bronchoscopy, so patient will be
notified of this change in plans on Monday. Patient was set-up
with outpatient follow-up at the thoracic oncology clinic and
with her PCP for further [**Name9 (PRE) 8019**] of this probably malignancy.
.
TRANSITIONAL ISSUES
- Patient will need to obtain a biopsy of this mass for tissue
diagnosis that will determine potential treatment options.
Patient is scheduled for an IR biopsy for [**9-13**], though
per IP, they will contact patient to try to obtain tissue via
bronchoscopy prior to this date. Patient will be seen in the
thoracic oncology clinic once tissue diagnosis has been made.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
(Primary)
New lung mass
Left upper lobe lung collapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 91176**],
You were admitted to [**Hospital1 18**] because you were becoming
increasingly short of breath while walking over the past few
weeks. Chest X-ray and CT scan of the Chest showed a mass that
has caused collapse of part of your left lung. Since you were
feeling quite well, we decided that you can see interventional
radiology as an outpatient to get a tissue sample (biopsy) of
the mass. You can then be seen in the thoracic oncology clinic
where they can make a final diagnosis and decide what treatment
options are available.
.
Please contact [**Name (NI) 91177**], your nurse [**First Name8 (NamePattern2) **] [**Name (NI) 778**], at [**Telephone/Fax (1) 67596**] if
you develop severe shortness of breath or any other troubling
symptoms. Someone will be available at that number 24 hours a
day.
.
No medications were added or changed during this admission.
Followup Instructions:
The following appointments were made for you:
.
1. Interventional Radiology
Location: Radiology Care Unit, [**Location (un) **], [**Hospital Ward Name 121**] Building at [**Hospital1 18**]
[**Hospital Ward Name 517**]
When: [**2185-9-13**]. Please arrive at 7:30am for a 9am
procedure.
Other: You will be called by Interventional Radiology on Monday
with further instructions on how to prepare for the procedure.
.
2. Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
When: [**Last Name (LF) 2974**], [**9-16**], 9:40AM
.
You will also be contact[**Name (NI) **] by the Thoracic [**Hospital **] Clinic.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
ICD9 Codes: 5180, 5990 | [
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train_41866 | completed | cffa0186-b9e8-46c0-9ec2-da301cbd0f1e | Medical Text: Admission Date: [**2195-9-14**] Discharge Date: [**2195-9-26**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
[**Age over 90 **]F s/p recent right AKA, who presents with fever, UTI and
dyspnea.
Major Surgical or Invasive Procedure:
G tube placement
History of Present Illness:
Transferred from rehab for fevers to 101, dyspnea.
Past Medical History:
HTN, DVT,CRI, Hypothyriod,CAD,OA, severe dementia
Social History:
in nursing home since discharge from [**Hospital1 18**]
Family History:
daughter [**Name (NI) **] is HCP
Physical Exam:
T 101 62 90/60
not oriented
RRR
lungs CTA B
soft nontender
Right AKA site w/o cellulitis or fluctuance
Pertinent Results:
on admission:
WBC 25
U/A: +bacteria, +WBC
C diff+ x1
RUE US: near occlusive subclavian DVT
Brief Hospital Course:
[**9-14**]: admitted with UTI to [**Hospital Ward Name **] 9. also worrisome for failure
to thrive, which calorie counts confirmed.
[**9-21**]: per g-j tube placed in IR.
[**9-23**]: transferred to ICU setting for respiratory failure & was
intubated.
[**9-25**]: extubated after family meeting opting to make patient
DNR/DNI. transferred to floor & diuresed.
[**9-26**]: respiratory failure led to ms [**Known lastname 62288**]' death. see event
note. family, attending & admitting notified.
Medications on Admission:
Cogard 20', megace 400', synthriod 75', CaCO3 100q12
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
HTN,
CRI,
Hypothyriod,
CAD,
OA,
severe dementia,
UTI,
pneumonia,
right SCV deep vein thrombosis
Discharge Condition:
deceased
Discharge Instructions:
na
Followup Instructions:
na
Completed by:[**2195-9-26**]
ICD9 Codes: 5990, 5070, 4275, 5849, 0389, 4280, 2449, 4019 | [
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train_42320 | completed | 271acf19-be71-4edb-b1fe-63cd32b97acc | Medical Text: Admission Date: [**2132-8-5**] Discharge Date: [**2132-8-14**]
Date of Birth: [**2083-1-21**] Sex: F
Service: MEDICINE
Allergies:
Betadine / Iodine / Nitroglycerin Transdermal / Gabapentin
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Seizure and hypertensive emergency
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
49 y/o female with ESRD s/p 2 failed renal transplants on HD,
chronic HTN, T1DM s/p pancreas transplant, and CAD who presented
to the ED after a witnessed seizure. History is obtained through
hospital records and the patient's husband. At the time of
presentation to the MICU, pt was a poor historian and could not
relate her PMH or home medications.
.
The patient awoke around 3AM on the day of presentation and her
husband described her as confused and talking nonsense. This
episode resolved and the patient returned to sleep. In the AM on
the day of presentation, she was in her bathroom at home and her
husband witnessed a seizure around 7:30AM. He described tongue
biting and foaming of the mouth. He denies any incontinence;
however she does not make much urine and has an ileostomy. She
had tonic movements and her husband grabbed her hands and
lowered her to the ground. She sustained no head injury. EMS was
called and she was brought to the ED. She received Ativan 2 mg
IM which seemed to relieve some of her symptoms.
Past Medical History:
-s/p renal and pancreas transplant ([**2127-2-28**]; 2nd renal
transplant [**2128-3-4**]) for T1DM now with failed renal tx on HD
-CAD s/p CABG [**2-21**]
-Legally blind: cannot see anything in right eye due to diabetic
retinopathy and retinal detachment, and severely limited in left
eye
-Hypertension
-Osteopenia
-Depression
-Gastroparesis
-anemia
-CHF EF 30-35%
-Chronic diarrhea-with Cdiff and toxic megacolon [**10-26**] requiring
colectomy with ileostomy and ileostomy reversal in [**Month (only) 404**] of
[**2129**]
-Ventral hernia repair in [**2130-3-24**]
-history of VRE
-history of zoster (resolved)
-Polyneuropathy, felt to be due to CIDP
-Multiple SBOs
Social History:
Former CCU nurse, retired due to visual loss. 9 pk yr h/o
smoking, quit [**2107**]. No etoh/drugs. Uses walker at baseline.
Lives at home with husband. Manages all of her home meds.
Family History:
Adopted, unknown.
Physical Exam:
T 99 140/80 85 18 98/RA FS = 86
49 y/o female, not cooperative with history and exam. Poorly
answers questions, somnolent; rousable to loud voice and touch
HEENT: NC/AT. MMM. OP clear. Pupils equal and minimally
reactive.
Neck: Supple, no carotid bruits appreciated.
CV: 4/6 systolic murmur at LUSB with minimal radiation to
carotids.
Pulm: CTAB without any wheezes or crackles.
Abd: Soft, question of tenderness, ND, normoactive bowel sounds,
with large midline incision, stoma with stool/gas
Ext: No c/c/e. Evidence of recent vascular procedure on RLE.
Skin: No rashes.
Neuro: Somnolent. CNs difficult to assess secondary to AMS.
Moves all limbs equally, but not on command. Face symmetric.
Pertinent Results:
[**2132-8-5**] 09:12AM
WBC-5.1 RBC-3.25* HGB-12.7# HCT-36.7 MCV-113* MCH-39.1*
MCHC-34.6 RDW-18.9*
PLT COUNT-148*
NEUTS-73.6* LYMPHS-19.6 MONOS-5.4 EOS-1.1 BASOS-0.4
.
[**2132-8-5**] 09:12AM
GLUCOSE-88 UREA N-22* CREAT-5.2*# SODIUM-132* POTASSIUM-4.7
CHLORIDE-90* TOTAL CO2-23 ANION GAP-24*
ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-5.2* MAGNESIUM-1.8
ALT(SGPT)-13 AST(SGOT)-22 ALK PHOS-161* AMYLASE-47 TOT BILI-0.4
.
[**2132-8-5**] 09:12AM
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-POS
.
[**2132-8-5**] 09:12AM
cTropnT-0.10*
.
[**2132-8-5**] 09:29AM
LACTATE-4.4*
.
CT HEAD W/O CONTRAST Study Date of [**2132-8-5**] 10:11 AM
No hemorrhage, mass effect or edema. No significant change from
prior study.
.
ECG Study Date of [**2132-8-5**] 11:07:40 AM
Rate PR QRS QT/QTc P QRS T
91 146 114 400/448.71 75 76 112
.
EEG [**2132-8-7**]
This is an abnormal routine EEG in the waking and drowsy
states due to the presence of multifocal shar regions along with
multifocal mixed frequency slowing seen in the left and right
temporal
regions. The first finding suggests multiple areas of cortical
irritability which could serve as foci for epileptogenesis. The
second
finding suggests areas of subcortical dysfunction. No
electrographic
seizures were noted.
.
Patient refused both LP and MRI
Brief Hospital Course:
In the ED, intial vitals were T 98.8 HR 110 BP 222/125 RR 14 and
100%RA. She was given Ativan IV for a total of 4 mg. She was
given benadryl and Lopressor 5 mg IV x 2 and 25 mg PO. SBP
improved to the 180s. She was transferred to the MICU for BP and
neurological monitoring. Once hemodynamically stable, she was
transferred to the medical floor for continued work-up of her
seizure and hypertensive emergency.
.
# S/p seizure. Seizure activity was not observed while
inpatient. She was initially ruled out for toxic and metabolic
causes with blood toxicology and electrolyte testing. Head CT
was performed upon admit, and on hospital day #2 to assess for
acute intracranial pathology - both of which were negative.
Neurology was consulted and believed that multiple admissions
for confusion and elevated BP may represent missed seizures.
Per neuro recs, Mrs. [**Known lastname 13959**] was initially started on phenytoin
for seizure prophylaxis, but this medication was discontinued
and switched to Keppra once it was noted that phenyoin would
lower her tacrolimus level. Throughout her stay she refused
MRI and LP despite explanation that her immunocompromised state
caused increased concern for an intracranial infection. EEG was
performed and revealed no ongoing seizure. She was discharged
home on Keppra with Neurology follow-up.
- Keppra 37mg po BID
- Neurology follow-up [**Last Name (LF) 766**], [**2132-8-11**].
# Altered Mental Status. When admitted was altered mental
status, initially thought to be a post-ictal state. She was
treated with ativan for her seizure and transferred to the ICU
with some clearing of her mental status, however, by her third
day of hospitalization she continued to have altered mental
status of unclear etiology - whether due to benzodiazepines vs.
TCA withdrawal as her desipramine was held upon admit vs
metabolic vs hypertensive encephalopathy. Electrolyte and ABG
analysis were unrevealing. Hypertension was controlled and her
desipramine was restarted. On the seventh day of admission,
psychiatric consult was obtained and suggested avoiding benzos
and narcotics; and to use the single [**Doctor Last Name 360**] of haldol to control
her agitation. Following implementation of these suggestions,
her mental status improved dramatically and she was clear upon
discharge.
- Unclear etiology. Cleared with avoidance of benzos/narcotics;
haldol used for agitation.
.
# Fluctuating Blood Pressure - Admitted in hypertensive crisis
with BP likely elevated secondary to seizure and question of
recent compliance. Patient stated she take lopressor and
enalapril on a PRN basis at home as she often has low BP. She
takes them when her diastolic is 'greater than 100'. Was then
started on Metoprolol 25mg TID and lisinopril 5mg with good
control for 24 hours. She then became profoundly hypotensive to
SBP 70s, requiring TID midodrine and florinef per her home
regimen. She was normotensive upon discharge and these two
medications were continued.
- Discharged on midodrine and florinef
.
# s/p renal and pancreas transplant ([**2127-2-28**]; 2nd renal
transplant [**2128-3-4**]) for T1DM now with failed renal tx on HD.
Throughout stay was kept on HD schedule MWF and continued on
Bactrim prophylaxis. Renal medications of nephrocaps, procrit,
FeSO4 per HD protocol were continued. Immunosuppression of
imuran, prograf, and prednisone were continued at outpatient
levels. Prograf levels were monitored, and once noted to be low
secondary to phenytoin, the phenytoin was immediately
discontinued. Nephrology Transplant was consulted and
recommended Keppra for seizure management and reloading of
Prograf. Dosing was increased to 4mg po BID. On the day of
discharge, the level was therapeutic and per Transplant
pharmacy, she was discharged on her original dose of 2mg po BID.
- Continue tacrolimus 2mg PO BID
- Follow-up with Renal
- Continue all other outpatient medications as prescribed
.
# CAD s/p CABG [**2-21**]. Initial EKG changes were concerning for
ischemia, but resolved once HTN was controlled, most likely
consistent with demand in the setting of SBPs 220-240. Repeat
EKGs were monitored and cardiac enzymes were followed. CK and
troponin were elevated but were baseline in the setting of ESRD.
No elevation in CK-MB. Was briefly on BB and ACE-I, but both
were d/c due to hypotension.
- Continue outpatient aspirin.
- Instructed to follow-up with PCP concerning BB and ACE-I for
cardio-protection
.
# Asthma. Well controlled while inpatient without evidence of
acute flair.
- Discharge on outpatient medications
.
# Anemia: Chronic. Most consistent with ESRD, on pro-crit as an
outpatient, which was continued while inpatient.
.
# Chronic diarrhea: h/o Cdiff and toxic megacolon [**10-26**]
requiring colectomy with ileostomy and ileostomy reversal in
[**2129-12-24**]. Stoma was managed with routine nursing care.
Immodium was initially PRN, and she continued to have high
volume stoma output. When Immodium was scheduled [**Hospital1 **], stoma
output decreased dramatically and hypovolemia resolved.
- Immodium [**Hospital1 **]
.
#Diabetes Mellitis, Type 1 - Clinical cure s/p pancreatic
transplant. Did not require insulin while inpatient. One FS =
256. Transplant was consulted with concern for pancreas
rejection given period of low tacrilimus levels. Amylase and
lipase were checked and found to be normal. No evidence of
rejection. All AM FS below diabetic levels.
.
FULL CODE
Medications on Admission:
(per husband's documentation)
Prograf 2 mg PO BID
Prednisone 5 mg PO daily
Imuran 25 mg PO QOHS
ASA 81 mg PO daily
Folate 1 mg PO QHS
Bactrim SS 1 TAB PO QMWF
Lopressor 75 mg PO ?PRN
Enalapril 15 mg PO ?PRN
Atrovent INH
Astelin
Flovent
Ventolin INH
Restais gtt
Pred Forte gtt
Acular gtt
Zaditor gtt
Alrex gtt
Benadryl PRN
Tylenol PRN
Pseudophed PRN
Alka-Seltzer PRN
Procrit (at HD)
Iron (at HD)
Zemplar (at HD)
Fosrenol [**2124**] mg PO W/meals
Ambien PRN
Compazine PRN
Claritin 10 mg PO QAM
[**Doctor First Name **] PRN
Ibuprofen PRN
Midodrine PRN
Immodium PRN
Nephrocaps
Desiprimine 150 mg PO QHS
Lomotil PRN
Pepcid 10 mg PO QAM
Simethicone
Clonazepam PRN
Sensipar 30 mg PO daily
Discharge Medications:
1. Procrit 10,000 unit/mL Solution Sig: per HD protocol
Injection per protocol.
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QHS MWF.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO at bedtime.
5. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO QOHS.
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Atrovent 0.03 % Aerosol, Spray Sig: Two (2) Sprays Nasal once
a day.
8. Astelin 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal once
a day.
9. Flovent HFA 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation once a day.
10. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) Puff Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. Pred Forte 1 % Drops, Suspension Sig: One (1) gtt os
Ophthalmic Q3D.
12. Acular 0.5 % Drops Sig: One (1) gtt os Ophthalmic Q3D.
13. Zaditor 0.025 % Drops Sig: One (1) gtt os Ophthalmic once a
day as needed for conjunctitvis.
14. Zemplar 5 mcg/mL Solution Sig: Per HD protocol per protocol
Intravenous QMWF.
15. FeSO4 Sig: Per HD protocol Per HD protocol Hemodialysis
QMWF.
16. Lanthanum 500 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia. Tablet(s)
18. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for nausea.
19. Claritin 10 mg Tablet Sig: One (1) Tablet PO QAM.
20. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO at bedtime.
21. Imodium A-D 2 mg Tablet Sig: 4-8 Tablets PO three times a
day as needed for increased stoma output.
22. Lomotil 2.5-0.025 mg Tablet Sig: Two (2) Tablet PO three
times a day.
23. Pepcid AC 10 mg Tablet Sig: One (1) Tablet PO QAM.
24. Simethicone 125 mg Capsule Sig: Four (4) Capsule PO three
times a day.
25. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
26. Sensipar 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
27. Keppra 250 mg Tablet Sig: 1.5 Tablets PO twice a day: Also
take one additional tablet (250mg) after each HD on MWF.
Disp:*110 Tablet(s)* Refills:*2*
28. Desipramine 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
29. Midodrine 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
30. Florinef 0.1 mg Tablet Sig: One (1) Tablet PO QMWF.
31. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Seizure d/o, hypertensive emergency
Secondary: Diabetes mellitis type 1 s/p resolution with
successfull pancreatic transplant, hypotension,
immunosuppression, ESRD, blindness, AMS, asthma, anemia, CAD s/p
CABG, CHF (EF = 30-35%).
Discharge Condition:
Good. Afebrile and normotensive with stable mental status.
Discharge Instructions:
You have been hospitalized for both hypertensive emergency and a
new witnessed seizure. Once admitted you were transferred to
the ICU and treated with blood pressure and antiseizure
medications. You were also seen by Neurology, Psychiatric and
Renal specialists. Once you were stable and your blood pressure
was controlled, you were transferred to the floor. Your
hemodialysis was continued while you were here. On the day of
discharge your blood pressure was well controlled and you had
not had any seizure activity while in the hospital.
.
Return to the emergency department immediately should you have
another seizure, blood pressure not controlled by your current
medications or have any other symptoms that concern you.
.
While in the hospital the following medications have been
changed:
--You were previously on metoprolol (lopressor) 75mg and
enalapril 15mg PRN. While inpatient your blood pressure was
very high requiring daily metoprolol, but then became very low.
We are discharging you on Florinef 0.1mg QMWF and Midodrine 5 mg
PO Q6H. This is your regular dose of Florinef and an increase
in your Midorine dosing. You should follow-up with your on PCP
to discuss this while continuing to monitor your blood pressure
at home and HD.
--Because you have a new diagnosis of seizure disorder, you have
been started on antiseizure medication. You should continue
taking Keppra 375mg po BID each day, with a 250mg extra dose
after each dialysis per Neurology recommendations.
--In the hospital, you were briefly treated with dilantin for
your seizures. This lowered your ProGraf (tacrolimus) level.
Renal transplant recommended briefly increasing your tacrolimus
dosing to get back to therapeutic levels. Today your level is
therapeutic, and so you are being discharged home on your
previous dose of 2mg po BID.
.
Continue all other medications as prescribed.
.
Attend all scheduled outpatient appointments.
Followup Instructions:
Follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],[**Telephone/Fax (1) 3506**]
Wednesday, [**2132-9-17**] at 12pm.
.
Follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (STitle) **], [**Telephone/Fax (1) 250**]
Wednesday, [**2132-9-17**] at 11am.
.
Continue hemodialysis MWF.
.
Call your Renal physician to make [**Name Initial (PRE) **] follow-up appointment in the
next 1-2 weeks to monitor your Prograf levels.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
ICD9 Codes: 5856, 4280, 2875, 3572 | [
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train_37179 | completed | d3d98e48-b8ee-45ed-886e-7d6934bfa8fb | Medical Text: Admission Date: [**2177-2-12**] Discharge Date: [**2177-2-15**]
Date of Birth: [**2119-7-28**] Sex: M
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: This patient is a
57-year-old man with a history of diverticulosis,
esophagitis, GERD, who presented to [**Hospital **] Hospital on
[**2177-2-8**] with weakness and was found to have a
hematocrit of 18.4 from a GI bleed. The patient said that he
the patient had an extensive workup which included an EGD on
[**2177-2-8**] which showed erosive gastritis with a question
of slight blood but no active site of bleeding. There was
also note of a nonobstructing thin Schatzki's ring.
On [**2177-2-9**], the patient had a large amount of melena
and the patient's hematocrit went from 18.4 to 25 after 5
performed which showed old blood in the fundus, approximately
175 cc.
The patient then was taken to a tagged red blood cell scan
which was positive for bleeding in the mid and left abdomen.
On [**2177-2-10**], the patient was taken to Angiography which
was a normal study and did not show any evidence of
extravasation or site of bleeding. IgG for H. pylori was
reportedly negative. The patient received a total of 13
units at the outside hospital of packed red blood cells as
well as 2 units of FFP.
On [**2177-2-12**], the patient's hematocrit dropped from 30 to
26.7 and the patient was transferred to the [**Hospital6 1760**] for further evaluation.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Esophagitis/GERD.
3. Hypercholesterolemia.
4. Diverticulitis.
5. History of GI bleeding.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Accupril.
2. Lipitor.
3. Norvasc.
4. Iron.
5. Pepcid.
MEDICATIONS ON TRANSFER:
1. Protonix 40 mg IV q. 24 hours.
2. Tylenol.
SOCIAL HISTORY: The patient is married with one 14-year-old
son. [**Name (NI) **] works as a trouble shooter for a high-tech equipment
company. He drinks approximately one to two beers per week.
He denied any tobacco or drug use.
FAMILY HISTORY: The patient's father has coronary artery
disease.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient is
a middle-aged man in no acute distress. Vital signs:
Temperature 98.6, heart rate 77, blood pressure 124/61,
respiratory rate 13, oxygen saturation 100% on room air.
HEENT: Pupils equal, round, and reactive to light,
extraocular movements intact, oropharynx clear. Lungs: Clear
to auscultation bilaterally. HEENT: Regular rate and
rhythm. Abdomen: Soft, nontender, nondistended, positive
bowel sounds. Extremities: No clubbing, cyanosis or edema
with 2+ peripheral pulses.
LABORATORY DATA: White count 9.2 with a hematocrit of 24.4,
platelets 235,000. Sodium 142, potassium 3.8, chloride 110,
bicarbonate 26, BUN 32, creatinine 0.9, glucose 116, calcium
7.9, magnesium 1.8, phosphate 3.6, INR 1.2.
Urinalysis: Negative.
EKG: Normal sinus rhythm at a rate of 80 with normal axis,
QTC at 449, no acute ST or T wave changes.
HOSPITAL COURSE: 1. GASTROINTESTINAL: The patient was
taken to Endoscopy on [**2177-2-13**] where they found
gastritis, gastric arteriovenous malformations that were
cauterized successfully and duodenitis. It was thought that
the gastric AVMs were likely the cause of the patient's
massive GI bleed. The patient was also started on Protonix
40 mg p.o. b.i.d. and the patient's diet was advanced slowly
from a clear liquid diet to a full low-sodium diet.
The patient did not have any further episodes of GI bleeding
while in the hospital; however, he did require an additional
2 units of packed red blood cells to maintain his hematocrit
above 26. The patient's hematocrit was stable after
endoscopy and upon discharge his hematocrit was 28. The
patient was tolerating a normal diet without any difficulty
and was passing brown nonmelenic stools. The patient will
need a repeat endoscopy for follow-up in three to four weeks
with Dr. [**Last Name (STitle) 1940**].
2. GENITOURINARY: The patient complained of difficulty
emptying his bladder and increased urinary frequency on [**2177-2-15**] after his Foley catheter was discontinued on [**2177-2-14**]. The patient had a Foley catheter in place for
approximately five to six days. The patient reports that
prior to Foley catheterization he only had mild difficulty in
initiating urination but did not have any problems emptying
his bladder. A urinalysis was obtained on [**2177-2-15**]
which was negative for any evidence of infection. A postvoid
residual was checked and revealed 990 cc of urine in his
bladder. It was thought that the patient may either have an
obstructive lesion, however, the patient's prostate was
normal on examination without tenderness.
In addition, it is possible that the patient may have had a
neurogenic bladder as a result of the Foley catheterization
or that the Foley catheterization exacerbated the patient's
prior mild case of urinary obstruction. The patient will be
discharged home with a leg Foley bag and he will follow-up
with his primary care physician in two days for removal of
the catheter. He will also be started empirically on
Levaquin 250 mg p.o. times five days for empiric treatment
even though the patient's urinalysis was negative for
infection.
If the patient is not able to urinate upon removal of the
Foley catheter then the patient will need urologic follow-up
with possible urodynamic studies and cystoscopy.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSIS:
1. Gastrointestinal bleed secondary to gastric arteriovenous
malformation.
2. Urinary retention with questionable obstruction.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. b.i.d.
2. Levaquin 250 mg p.o. q.d. times five days.
3. Atorvostatin 10 mg p.o. q.d.
4. Norvasc 5 mg p.o. q.d.
5. Accupril 10 mg p.o. q.d.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]
in approximately three to four weeks for repeat endoscopy.
The patient will also follow-up with his primary care
physician for his urinary obstruction/Foley catheter.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13467**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2177-2-15**] 12:10
T: [**2177-2-16**] 18:49
JOB#: [**Job Number 48966**]
ICD9 Codes: 2720, 4019 | [
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train_37906 | completed | b9d93575-0f16-45dd-95f2-ae088477cc75 | Medical Text: Admission Date: [**2180-6-30**] Discharge Date: [**2180-7-4**]
Date of Birth: [**2132-12-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
Ms. [**Known lastname **] is a 47yo chinese speaking female with past medical
history significant for GERD, cognitive delay, and anemia
(vitamin B12 deficiency), who presented to the emergency room
complaining of epigastric pain for 4 days acompanied with dark
brownish colored vomitus x2 at home over past 24 hours. She also
had one episode diarrhea yesturday. Mild waves of intermittent
nausea as well. Sister explains that patient c/o "dark black"
stools over past month. No NSAIDs per family.
In the ED, initial VS were: T 97.8F, HR 100, BP 129/85, RR18 and
100% RA. She had an OG lavage which showed coffee ground
materials mixed with clots, a total of 250cc lavaged. No
associated hypotension despite GI bleeding. One month ago
patient had HCT of 41 and it is now 33 on ED labs. Rectal exam
in ED was guaiac negative.
She was given 2L NS IVFs, morphine 2mg for abdominal pain, 80 IV
Protonix and then Protonix drip started.
GI service consulted and advised close ICU monitoring overnight
with plan for blood transfusions to keep HCT goal >30 with plan
for EGD early in morning.
Urinalysis in ED also remarkable for +blood, +bacteria, moderate
leuks and >50 WBCs which was concerning for UTI. Patient has no
fevers, chills, flank area pains but does endorse mild lower
abdominal pain at suprapubic area.
On arrival to [**Hospital Unit Name 153**], she appeared to be in no acute distress and
was accompanied by her mother. Initial vital signs were : T
99.6F, BP 114/87, HR 92, RR 19 and O2 sat 98%.
Past Medical History:
-GERD
-cognitive delay /anoxic brain injusry from birth
-Anemia
-Vit B12 deficiency
-Torticollis
-surgery in past to remove left ovary / ?cyst per sister
Social History:
She lives with her sister [**Name (NI) **]. [**Name2 (NI) **] with her sister [**Name (NI) **] as
well and mother lives nearby. Moved to US with her parents
several years ago. She does not use drugs, drink, or use any
tobacco. She is unemployed. Walks with lean to right side at
baseline per sister.
Family History:
Mother with HTN, hyperlipidemia in her father. [**Name (NI) **] family history
of neurologic disorders.
Physical Exam:
Vitals: T 99.6F, BP 114/87, HR 92, RR 19 and O2 sat 98%.
General: patient alert to person only, no acute distress, unable
to speak english, posture with right sided torticollis-like
positioning at times
HEENT: PERRLA,EOMI. Gaze is disconjugate and left eye with
slight lower eye lid as compared to right. Sclera anicteric, dry
MM, poor dentition but oropharynx otherwise clear, nares 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. Tender with palpation over epigastric area and
mildly tender to palpation over left lower abdomen at suprapubic
border, non-distended, bowel sounds present and normoactive x 4
quadrants, no rebound tenderness or guarding, no organomegaly
(guaiac negative in ED)
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2180-7-1**] Upper Endoscopy: Ulcer in duodenal bulb
H.pylori: POSITIVE BY EIA.
HCT trend: 32 -> 24 -> 34 -> 38 (discharge)
Ferritin: 11
Brief Hospital Course:
1. Duodenal ulcer: Admitted to ICU with upper GIB. Endoscopy
showed duodenal ulcers and h.pylori returned positive. She was
treated at endoscopy and received 2 units of pRBC. Her HCT
improved and was 38 at the time of discharge. A prescription
for triple therapy was called into her pharmacy as these results
turned positive after discharge.
2. Anemia: Mostly due to acute blood loss, though ferritin of
11 suggests some underlying iron deficiency. Repeat HCT and
ferritin may be of value long-term.
Medications on Admission:
1. Omeprazole 20mg [**Hospital1 **]
2. Calcium/Vitamin D supplement
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Calcium Oral
3. Vitamin D Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer
GI bleed
Discharge Condition:
Hemodyamically stable with a stable hematocrit
Discharge Instructions:
You were admitted and found to have an ulcer in the duodenum.
To help this heal, we are proscribing a new medications
(pantoprozole). Please be sure to take this until you are seen
in follow-up.
Followup Instructions:
We are working on an appointment for you to see your primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The office will contact you with an
appointment. If you have not heard from them, please call
[**Telephone/Fax (1) 10349**].
ICD9 Codes: 2851, 5990 | [
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train_37369 | completed | 73c935bf-94e2-4f81-937b-4ca9dff06255 | Medical Text: Admission Date: [**2148-10-29**] Discharge Date: [**2148-10-29**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 89 year-old
female with a history of congestive heart failure and
osteomyelitis of her left femur who presented with shortness
of breath and decreased O2 saturations on room air in the
setting of two days of foul smelling diarrhea. The patient
lives at [**Hospital3 2558**] and was transferred today to [**Hospital1 1444**] Emergency Department, because
she was noted to have persistent oxygen saturations in the
low 90s and high 80s on 12 liters of oxygen. In addition to
being hypoxic while in the Emergency Department she was noted
to be hypotensive to 90/palpable with a temperature of 101.4.
With the exception of the story of two days of foul
smelling diarrhea there was no further documentation.
While in the Emergency Department the patient was intubated
for hypoxic respiratory failure, received 1 liter of normal
saline and was started briefly on Dobutamine drip for her
hypotension. In addition, she received Vancomycin, Flagyl
and Ceftriaxone and transferred to [**Hospital Ward Name 332**] Intensive Care Unit
for further management.
PAST MEDICAL HISTORY: 1. Osteomyelitis of the left femur
that has been chronic. The patient has been wheel chair
bound for the last year. 2. Congenita one kidney status
post nephrostomy tube in the left functional kidney with a
history of urosepsis in the past. Her nephrostomy tube was
changed in [**2148-10-13**]. 3. Hypothyroidism. 4.
Congestive heart failure with a normal ejection fraction.
Echocardiogram in [**2147-2-13**] showed moderate AS, mild
MR, moderate TR, moderate pulmonary hypertension. 5. ITP
plus Cipro exposure. 6. Depression. 7. History of C-diff
colitis. 8. Dementia.
ALLERGIES: Aspirin causing a rash. Penicillin causing
difficulty breathing, codeine causes vomiting and Cipro
causing ITP.
MEDICATIONS ON ADMISSION: Iron 325 mg po q day, Levoxyl 50
mg po q day, vitamin B, vitamin E, vitamin C. Natural tears
to the eyes. Zoloft 50 mg po q day, Megace 200 mg po b.i.d.,
Milk of Magnesia 30 mg po prn, Robitussin 5 ml po q 4 to 6
hours prn, Tylenol prn, Mylanta prn.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives in [**Hospital3 2558**] for the
last eight years. Her daughter is heavily involved in her
care and is her health care proxy.
PHYSICAL EXAMINATION: Temperature 98.6. Pulse 109. Blood
pressure 102/37 with a map of 60. O2 sat 100% on 40% oxygen
vented at AC, 600 by 10 with a PEEP of 5. The patient was
paralyzed and sedated. Her lungs were clear to auscultation
bilaterally. Her heart was regular with faint heart sounds.
There were no murmurs appreciated. Belly was soft and
nontender. There were hyperactive bowel sounds. Extremities
showed no clubbing, cyanosis or edema. However, they were
cool to touch. There were good distal pulses.
LABORATORIES ON ADMISSION: White blood cell count 3.2.
Differential of 61 neutrophils, 3 bands, 34 lymphocytes, 2
monocytes, hematocrit 30.7, platelet count of 317, anion gap
was 14. Chem 7 showed sodium of 143, potassium 4.8, chloride
115, bicarb of 14, BUN 40, creatinine 1.9, which is up from
her baseline of 1, glucose 129. CK 53, troponin less then
0.3. Calcium 8.7, phosphate 3.5, magnesium 2.5. Her INR was
1.4, arterial blood gas 7.3, 28, 448, 100% O2. Chest x-ray
showed ECT in left main stem, blunting of the left
costophrenic angle - ECT tube was pulled back by 3 cm. CT of
the abdomen showed atrophic right kidney with multiple
stones. Percutaneous nephrostomy tube was in place in the
left kidney. A small amount of air in the left kidney.
There were bilateral pleural effusion noted. Her urinalysis
showed red cloudy urine with specific gravity of 1.02.
Serologic blood positive nitrites, more than 300 protein,
negative glucose, trace ketones, small bili, pH of 7.5, large
leukocyte esterase. Numerous red blood cells.
Electrocardiogram showed sinus rhythm of 107, normal axis,
normal intervals, Q wave in 3. No change from the prior.
HOSPITAL COURSE: In summary, the patient is an 89 year-old
female with a single kidney status post nephrostomy tube
changed recently who presents with hypertension and hypoxia
in acute renal failure. The patient's blood pressure
remained stable at approximately 100 systolic overnight off
of the pressors. She was continued on her antibiotics
including Flagyl, Ceftriaxone and Vancomycin for coverage for
urosepsis as well as C-diff. In the morning following
admission the patient's blood pressure was noted to be very
labile all the way to 40s. A family discussion was
undertaken and based on the patient's poor prognosis as well
as poor quality of life prior to the hospitalization the
decision was made to withdraw care. The patient's
antibiotics and fluids were stopped. She was extubated to
room air. She passed away at 4:03 p.m. on [**2148-10-29**]. The family was present at bedside and her daughter
[**Name (NI) **] [**Name (NI) **] refused postmortem examination. Her primary
care physician was notified.
DISCHARGE DIAGNOSES:
1. Probable urosepsis.
2. Hypoxic respiratory failure.
3. Acute renal failure.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2148-10-30**] 11:18
T: [**2148-11-5**] 06:06
JOB#: [**Job Number 9791**]
ICD9 Codes: 0389, 5185, 5849, 2762 | [
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train_37220 | completed | a4b0a3ec-e78b-4737-b53a-9ca74cc577b8 | Medical Text: Admission Date: [**2171-11-8**] Discharge Date: [**2171-11-17**]
Date of Birth: [**2171-11-8**] Sex: M
Service: NB
DISCHARGE DIAGNOSIS: Premature triplet number 2, 34 and 3/7
weeks gestation.
Probable PPS murmur.
HISTORY OF PRESENT ILLNESS: The infant is the former 2.475
kg male triplet number 2 born at 34 and 3/7 weeks to a 36-
year-old, gravida 2, para 1, now 3, living 4, female.
Prenatal screens reveal she is A positive; remaining prenatal
screens were noncontributory.
She had a previous full-term male infant born in [**2170**] by
cesarean section and has a history of a tubal factor 4
infertility with a myomectomy in [**2167**] and current fibroids.
She has a history of a positive PPD with a negative chest x-
ray.
This pregnancy was notable for IVF triplets, dichorionic,
triamniotic. Preterm labor was at 30 weeks gestation
controlled with p.o. Terbutaline, and she presented on the
day of delivery to the OB physician's office with 3 plus
proteinuria for which she was admitted to [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **], and the decision was made to
deliver by cesarean section.
This infant's Apgar scores were 8 and 9. The infant was
admitted to the Newborn Intensive Care Unit at [**Hospital3 **]
Hospital weighing 2.475 kg and 47.5 cm head circumference,
34.5 cm, appropriate for gestational age.
HOSPITAL COURSE: Respiratory: The infant was initially
tachypneic but remained in room air. He had no apnea or
bradycardia of prematurity.
Cardiovascular: On day of life 6, a soft grade [**1-18**] murmur
was heard at the lower left sternal border, radiating out to
the axilla and both scapula and was thought to be consistent
with peripheral pulmonary stenosis murmur. This was
discussed with the mother.
Infectious disease: There were no risk factors for sepsis.
The mother was negative for group B strep, and the infant's
were delivered for maternal indications. The infant's were
never started on antibiotics.
Feeding and nutrition: At discharge, the infant weighed
2.460 kg, was feeding ad lib and occasionally breast feeding.
He was discharged home on either mother's milk or NeoSure.
Immunizations: Hepatitis B immune vaccine was given on
[**11-13**].
Circumcision: Performed on [**11-15**] with good result.
Gastrointestinal: The infant had a peak bilirubin of 6.2 and
required no treatment.
The infant was discharged home on [**11-17**]. A visiting
nurse is to come to the home the day postdischarge, and the
mother is to see private pediatrician, Dr. [**Last Name (STitle) 57649**] at
[**Hospital1 **], [**Location (un) 1468**] Center.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2171-11-18**] 09:42:37
T: [**2171-11-18**] 09:57:31
Job#: [**Job Number 57650**]
ICD9 Codes: V053 | [
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train_37748 | completed | e96e63b8-4db3-4f23-9804-ce64cd5aa1d8 | Medical Text: Admission Date: [**2153-12-23**] Discharge Date: [**2153-12-23**]
Date of Birth: [**2120-12-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is a 32 yo woman with no PMH who presented to the ED
with three days of cough and fever. She reports that her cough
was non-productive and that she had no hemoptysis.
She saw her PCP on the day of presentation, who prescribed her
azithromycin. After taking the first dose, however, she had
three loose stools, and so she presented to the [**Hospital1 18**] ED.
In the ED, her initial VSs were 102.2, 148, 130/79 18 98% on RA.
She received 4 L NS and levofloxacin 750 mg IV and was
transferred to the [**Hospital Unit Name 153**] for futher care.
In the [**Hospital Unit Name 153**], her only other complaint is of some mild chest pain
with coughing.
Past Medical History:
None
Social History:
denies tobacco, alcohol, drug use
Family History:
non-contributory
Physical Exam:
Vitals: T: 99.5 BP: 104/79 P: 98 R: 15 SaO2: 96% RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: no scleral icterus, MMM, no lesions noted in OP
Neck: supple, no significant LAD
Pulmonary: left lower lung field crackels, no wheezes or ronchi
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Pertinent Results:
[**2153-12-22**] 11:20PM WBC-3.4* RBC-3.79* HGB-11.4* HCT-33.1* MCV-87
MCH-30.1 MCHC-34.4 RDW-13.0
[**2153-12-22**] 11:20PM NEUTS-47* BANDS-46* LYMPHS-6* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-12-22**] 11:20PM PLT COUNT-161
[**2153-12-22**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2153-12-22**] 10:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2153-12-22**] 10:10PM URINE RBC-[**3-5**]* WBC-[**3-5**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2153-12-22**] 11:20PM GLUCOSE-125* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12
[**2153-12-22**] 11:48PM LACTATE-2.4*
[**2153-12-23**] 02:36AM LACTATE-1.3
[**2153-12-23**] 11:56AM WBC-4.9 RBC-3.55* HGB-10.4* HCT-31.0* MCV-87
MCH-29.2 MCHC-33.5 RDW-12.7
[**2153-12-23**] 11:56AM NEUTS-78* BANDS-11* LYMPHS-10* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-12-23**] 11:56AM PLT COUNT-129*
[**2153-12-22**] Chest Xray: Left lower lobe pneumonia.
Brief Hospital Course:
Ms. [**Known lastname **] is a 32 yo woman admitted with LLL pneumonia and evidence
of systemic inflammatory response on admission with hypotension,
fever, bandemia.
1)Left lower lobe pneumonia: Seen on chest xray, responded well
to initiation of IV antibiotics and IV fluids. Initially she
had a bandemia which improved on repeat following antibiotics.
She remained afebrile on the day of admission with stable blood
pressure. She had no respiratory distress and had a low PORT
score. She was discharged on the day of admission to complete a
7 day course of levofloxacin 750mg po. She was instructed to
follow up with her primary care doctor in [**1-2**] weeks and to
return to the hospital if her symptoms do not continue to
improve.
2)Hypotension - she was transiently hypotensive in ED with SBP
80's-90's, unclear baseline blood pressure. She was given 4L NS
and remained normotensive with resolution of tachycardia.
Hypotension likely due to early systemic inflammatory response
which resolved with IV levofloxacin.
3) Code status: FULL CODE
Medications on Admission:
none
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: Please take all of this prescription. Do not stop
early even if you are feeling better. .
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower lobe pneumonia
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because you have a bad
pneumonia which caused low blood pressure and high fever. You
were treated with antibiotics and intravenous fluids.
It is very important that you take the antibiotics as prescribed
for a total of 7 days to treat the pneumonia.
You should follow up with your primary care doctor within [**1-2**]
weeks to be sure that the pneumonia is fully treated and to have
a repeat chest xray.
You should call your doctor or go to the emergency department if
you experience fever >100.4, light headedness or fainting,
worsening cough or any other concerning symptoms.
Followup Instructions:
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
to follow up within 1-2 weeks.
ICD9 Codes: 0389, 486 | [
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train_37664 | completed | e8e88da0-613a-4640-bf91-658a1af930f3 | Medical Text: Admission Date: [**2132-1-2**] Discharge Date: [**2132-1-10**]
Date of Birth: [**2063-9-16**] Sex: M
Service:
ADMITTING DIAGNOSIS: Coronary artery disease, status post MI
in [**2119**], status post cath and PTCA at that time.
HISTORY OF PRESENT ILLNESS: This is a 68-year-old man with
coronary artery disease, status post MI in [**2119**], status post
cath and PTCA at that time with a negative stress test two
years ago. He complained of chest pain that began three days
before he came in while he was shovelling snow and was
relieved by rest. He does not take Nitroglycerin. He
characterized the chest pain as band-like pain around his
chest. He had no shortness of breath or nausea or vomiting
associated with that, no radiation of the chest pain.
Characterizes the pain as a [**2140-5-24**]. He then was relieved by
rest. He then woke up with chest pain that night. He came
to the Emergency Room on the 16th with chest pain and was
given Nitroglycerin and it was relieved. He then proceeded
to go to the cath lab. Please see full report for all the
details. Briefly, he had a normal left main coronary artery,
the LAD was calcified with minimal luminal irregularities,
80% mid lesions and 80% diagonal II. The left circumflex had
80% of the OM1 and right coronary artery was totally occluded
and he had 80% proximal, 90% mid with thrombus and sequential
80% PDA lesions. In the cath lab he had three right coronary
lesions stented and he tolerated that procedure well. He
also had an echocardiogram on the 17th. Please see report
for full details. Briefly, he had overall severely depressed
left ventricular systolic function, ejection fraction of 30%,
severe hypokinesis, akinesis of the apex, hypokinesis of the
inferior wall, mid apical segments of the anterolateral,
anterior septal walls, dyskinesis of the basal segments of
the inferior septal and inferior walls.
PAST MEDICAL HISTORY: Includes MI in [**2119**]. At that time he
had a catheterization. Also has prostate cancer,
hypertension, hypercholesterolemia.
MEDICATIONS: On admission included Atenolol, Vasotec and
Aspirin.
LABORATORY DATA: White blood cell count 5.3, hemoglobin
10.9, hematocrit 31.5 and platelet count 176,000. Sodium
140, potassium 3.9, CO2 29, chloride 102, BUN 15, creatinine
1.1 and glucose 99.
PHYSICAL EXAMINATION: On exam his sternum was stable, no
drainage coming from the sternum or from his leg incision.
He had a slight erythematous rash on his back. He was alert
and oriented, carotids with good upstroke, no bruits, no JVD.
His cardiovascular, he had a regular rate and rhythm, regular
S1 and S2, no murmurs, rubs or gallops. His abdomen was
soft, positive bowel sounds, his lungs were clear, no
crackles. Extremities with no edema. He had palpable pedal
pulses, warm extremities.
HOSPITAL COURSE: On [**1-4**] the patient went to the OR and had
a CABG times four, LIMA to the diagonal, SVG to the LAD, PL
in the OM1. He tolerated that procedure well. He came out
of the OR on an epi drip .04 and Propofol and the epi drip
and Propofol were weaned off that night and he was also
extubated that night. On postoperative day #1 the patient
went into a rapid atrial fibrillation with subsequent
decrease in blood pressure, systolic blood pressure of 80-90.
He received Lopressor at that time and was started on
Amiodarone. He also had complained of some left chest pain
and there were some ischemic changes on his EKG which later
was thought to be musculoskeletal pain because it was
relieved with Toradol. It was thought that the ST changes in
the lateral leads were due to pericarditis. After receiving
the Lopressor and the Amiodarone, the patient converted to
normal sinus rhythm. The patient was also started on
Neo-Synephrine at that time for a low blood pressure. On
postoperative day #2 the patient had a drop in hematocrit to
20 and he received two units of packed red blood cells for
that. He was weaned off the Neo on that day. He had a brief
episode of atrial fibrillation which was converted with 2.5
mg of Lopressor and on postoperative day #3 the patient was
transferred to Far 6. Upon transfer the patient went into
rapid atrial fibrillation again at a rate of around 150. He
received Lopressor 10 mg IV at that time and some magnesium.
He was continued on his Amiodarone and he converted to normal
sinus rhythm in the 70's and his Lopressor dose was
increased. Over the next several days the patient remained
hemodynamically stable, his activity level increased with the
help of physical therapy. He was able to ambulate around the
unit. His O2 sats on room air were 94% and he was ready for
discharge. On postoperative day #6 the patient was
discharged from the hospital. Vital signs at time of
discharge were 97.8, heart rate 81 and normal sinus rhythm,
respiratory rate 16, blood pressure 115/76, O2 saturation 95%
on room air. His weight was 80.2 kg, up from his
preoperative weight of 77 kg.
DISCHARGE MEDICATIONS: Lasix 20 mg po q d times one week,
Calcium Chloride 20 mcg po q d times one week, Plavix 75 mg
po q d, Amiodarone 400 mg po tid times two days, then [**Hospital1 **]
times one week and then q d, Lopressor 25 mg po bid,
Ciprofloxacin 500 mg [**Hospital1 **] times three days, Aspirin 325 mg po
q d, Lipitor 10 mg po q d, Percocet 1-2 tabs po q 4 hours prn
pain, Ibuprofen 400 mg po q 6 hours prn for pain, Colace 100
mg po bid. The patient is to follow-up with his primary care
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in one month. He is to
follow-up with Dr. [**Last Name (STitle) **] in one month.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post MI.
3. Status post angioplasty times three and CABG times four.
4. Hypertension.
5. Hypercholesterolemia.
6. Prostate cancer.
The patient was discharged to home.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 4060**]
MEDQUIST36
D: [**2132-1-10**] 11:47
T: [**2132-1-10**] 12:16
JOB#: [**Job Number 27062**]
ICD9 Codes: 9971, 4019, 2720, 412 | [
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train_34408 | completed | 2d27b6f7-dc1a-42ad-8379-de035749a5a0 | Medical Text: Admission Date: [**2173-12-27**] Discharge Date: [**2173-12-31**]
Date of Birth: [**2098-6-17**] Sex: F
Service: MEDICINE
Allergies:
Ceclor / Vasotec / Talwin / Vioxx / Allopurinol And Derivatives
/ Lyrica
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
left ankle pain
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 75 year-old Female with a PMH significant for IgM
MGUS, iron deficiency anemia, celiac disease, primary biliary
cirrhosis, HTN, diastolic dsyfunction, OSA, depression and
chronic venous insufficiency who recently presented to the [**Hospital1 18**]
ED ([**2173-12-25**]) with concern for right lower extremity cellulitis
and re-presented with right knee pain and hypotension.
.
She initially presented to the ED on [**2173-12-25**] with right foot pain
and swelling with erythema without fevers or chills. She was
prescribed Augmentin and Bactrim and discharged with close
follow-up. She had been having mild shortness of breath with
exertion and some URI symptoms with sore throat over several
weeks, and was taking Cipro PO for this. On the evening of [**12-26**],
she experienced a mechanical fall in the shower and from then on
had right lateral knee pain. She has known osteoarthritis and
the pain seemed similar. She returned to the ED on [**2173-12-27**] with
'knee buckling' and associated bilateral extremity pain. She
also had some chest pain and resting dyspnea transiently. She
had no joint pain or swelling; no erythema. In the ED, she had a
temperature of 101.9F and was given 1 gram of IV Vancomycin. She
was also transiently hypotensive to the 70-80s and received 1.5L
NS x 1 with improvement to the 90s. She was transferred to the
MICU - mentating well, with adequate urine output and without
lightheadedness or dizziness.
.
Upon admission to the MICU, she required Levaphed gtt to
maintain her systolic pressures and was having frequent ectopy
on telemetry. She was volume resuscitated with adequate UOP. Her
leukocytosis of 14.4 improved to normal with empiric IV
Vancomycin and Zosyn. Of note, her ESR and CRP were elevated.
Serial CXRs showed mild-to-moderate pulmonary edema and
cardiomegaly. Bilateral knee radiographs showed no evidence of
infection or joint effusion; and an attempt at right knee
arthrocentesis resulted in a 'dry tap'. Her leg erythema did
improve with empiric antibiotics. A 2D-Echo showed mild
symmetric LV hypertrophy, preserved LVEF function of 55%, with a
severe resting LV outflow tract obstruction. Overall, she
improved with volume resuscitation in the setting of her LVOT
obstruction noted on 2D-Echo; and she was weaned from pressor
support. She did have some left conjunctival irritation,
periobital swelling and photophobia develop on admission with a
pruritic left eye. She denies visual acuity changes.
.
On arrival to the floor, the patient is breathing comfortably.
She has no headache and vision changes. No chest pain or trouble
breathing. Her left eye is pruritic and she has some
photophobia.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. IgM Monoclonal gammopathy of unknown significance
2. Iron deficiency anemia
3. Celiac disease
4. Primary biliary cirrhosis
5. Hypertension
6. Obesity
7. Obstructive sleep apnea
8. History of depression
9. (?) Diabetes
10. Cervical stenosis
11. Lumbar spine, degenerative joint disease
12. Hyperparathyroidism
13. Vitamin D deficiency
14. h/o endometriosis
15. h/o colonic adenomas
16. Hemorrhoids
17. Osteoporosis
18. s/p appendectomy
19. Gout
20. Coronary artery disease (s/p LAD stenting in [**5-/2168**])
21. Septal hypertrophy (s/p alcohol ablation [**5-/2168**])
22. Diastolic dysfunction
23. Cholelithiasis
24. Allopurinol-induced vasculitis (?)
25. s/p shoulder surgery ([**2173-3-12**])
Social History:
Lives in [**Location 3786**], MA. Lives alone with her cat. In the past,
worked as an accountant. Divorced with one son. Quit smoking ten
years ago (previously had 20-pack-year), no alcohol use; no
recreational substance use.
Family History:
non-contributory.
Physical Exam:
ADMISSION EXAM:
.
VS: BP 80 / 50, temp 99, HR 80, RR 12, 100% RA
Gen: Caucasian female in NAD
Cardiac: Mild systolic murmur radiating to carotids, no
extrasystolic heart sounds
Pulm: clear bilaterally
Abd: soft, NT, ND, normoactive bowel sounds
Ext: blanching erythema noted in lower extremities up to the
level of the calf, 1+ lower extremity edema, slightly warm
bilaterally, normal range of motion
.
DISCHARGE EXAM:
.
VITALS: 98.9 98.2 63-81 89-148/41-89 16 96% RA
I/Os: 530 | 870 Foley (LOS +2.8L)
GENERAL: Appears in no acute distress. Alert and interactive,
elderly female.
HEENT: Normocephalic, atraumatic. EOMI. PERRL (4-2 mm). Left
conjunctival irritation with normal pupillary response; mild
left periorbital edema with mild erythema. Nares clear. Mucous
membranes moist.
NECK: supple without lymphadenopathy. JVD 2-3cm just above the
clavicle at 90-degrees.
CVS: Regular rate and rhythm, 2/6 systolic murmur at LLSB, no
rubs or gallops. S1 and S2 normal.
RESP: Decreased breath sounds at bases bilaterally with faint
inspiratory crackles at right > left base. No wheezing, rhonchi.
Stable inspiratory effort.
ABD: soft, obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing, 2+ peripheral pulses; right knee
with vertical well-healed scar; bilateral knees with minimal
swelling, no erythema or fullness; [**11-22**]+ pitting edema
bilaterally to upper shins
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
Pertinent Results:
ADMISSION LABS:
.
[**2173-12-27**] 12:55PM BLOOD WBC-14.4* RBC-4.15* Hgb-11.7* Hct-34.3*
MCV-83 MCH-28.2 MCHC-34.1 RDW-14.9 Plt Ct-311
[**2173-12-27**] 12:55PM BLOOD Neuts-92.4* Lymphs-3.7* Monos-2.9 Eos-0.3
Baso-0.6
[**2173-12-28**] 11:38AM BLOOD ESR-62*
[**2173-12-27**] 12:55PM BLOOD Glucose-89 UreaN-36* Creat-1.8* Na-133
K-2.8* Cl-97 HCO3-17* AnGap-22*
[**2173-12-27**] 12:55PM BLOOD ALT-33 AST-45* LD(LDH)-288* AlkPhos-97
TotBili-0.4
[**2173-12-27**] 12:55PM BLOOD Albumin-3.6 Calcium-8.4 Phos-4.2 Mg-1.7
[**2173-12-28**] 03:56AM BLOOD Cortsol-21.9*
[**2173-12-28**] 03:56AM BLOOD CRP-179.5*
[**2173-12-27**] 12:55PM BLOOD IgG-846 IgA-54* IgM-358*
[**2173-12-27**] 09:06PM BLOOD Type-[**Last Name (un) **] Temp-36.9 pO2-77* pCO2-34*
pH-7.35 calTCO2-20* Base XS--5 Intubat-NOT INTUBA Comment-GREEN
TOP
[**2173-12-27**] 09:06PM BLOOD Glucose-90 Lactate-1.3 K-3.0*
[**2173-12-27**] 09:06PM BLOOD freeCa-1.05*
.
PERTINENT AND DISCHARGE LABS:
.
[**2173-12-31**] 07:55AM BLOOD WBC-8.2 RBC-4.00* Hgb-11.0* Hct-32.2*
MCV-81*# MCH-27.5# MCHC-34.2 RDW-15.5 Plt Ct-341#
[**2173-12-28**] 03:56AM BLOOD PT-17.7* PTT-29.5 INR(PT)-1.7*
[**2173-12-28**] 11:38AM BLOOD ESR-62*
[**2173-12-31**] 07:55AM BLOOD Glucose-94 UreaN-11 Creat-0.8 Na-141
K-3.8 Cl-109* HCO3-22 AnGap-14
[**2173-12-28**] 03:56AM BLOOD ALT-32 AST-47* LD(LDH)-148 AlkPhos-78
TotBili-0.4
[**2173-12-31**] 07:55AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.1
[**2173-12-28**] 03:56AM BLOOD Cortsol-21.9*
[**2173-12-28**] 03:56AM BLOOD CRP-179.5*
[**2173-12-27**] 12:55PM BLOOD IgG-846 IgA-54* IgM-358*
[**2173-12-31**] 07:55AM BLOOD Vanco-14.8
.
URINALYSIS: clear, negative for LE, negative for Nitr, no
protein
.
MICROBIOLOGY DATA:
[**2173-12-27**] Blood cultures (x 2) - pending
[**2173-12-27**] Urine culture - negative
[**2173-12-27**] MRSA screen - negative
[**2173-12-28**] Blood culture - pending
.
IMAGING:
[**2173-12-27**] CHEST (PA & LAT) - Mild interstitial edema. Recommend
post-diuresis films to exclude underlying subtle pneumonia.
.
[**2173-12-27**] TTE - The left atrium is dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP > 18mmHg). There is a severe resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (?#) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad. Compared
with the prior study (images reviewed) of [**2168-3-18**], tissue
Doppler imaging now suggests increase left ventricular filling
pressure. The left ventricular outflow gradient is similar.
.
[**2173-12-28**] KNEE (AP, LAT & OBLIQUE) - No radiographic evidence for
infection in either the right or left knee. No joint effusion on
either side. If there is an area of soft tissue swelling on
physical exam that is concerning for infection, then further
assessment with MRI, CT or ultrasound could be performed.
Brief Hospital Course:
75F with a PMH significant IgM MGUS, iron deficiency anemia,
celiac disease, primary biliary cirrhosis, hypertension, chronic
diastolic heart failure, and chronic venous insufficiency who
recently presented to the [**Hospital1 18**] ED ([**2173-12-25**]) with concern for
right lower extremity cellulitis who was treated with PO
antibiotics, and was re-admitted with probable sepsis ans septic
shock.
.
#Probable sepsis and septic shock due to lower extremity
cellulitis:
Patient was admitted with a presumed lower extremity cellulitis
after failing Bactrim and Augmentin PO associated with lower
extremity swelling and erythema. She initially was in septic
shock with hypotension requiring IVF and 24 hours of vasopressor
support in the MICU. Her antibiotics were broadened to
Vancomycin/Zosyn. Leukocytosis improved and swelling, erythema
resolved. Knee radiographs were unrevealing. Right knee
arthrocentesis was attempted and was "dry". Blood and urine
cultures were negative. Although it was not completely clear if
the cellulitis was the cause of hypotension, patient endorsed no
other symptoms to suggest another source of dehydration or other
infection. Therefore, patient was continued on a 7-day course of
Vancomycin.
.
#Chronic diastolic heart failure/HYPERTROPHIC CARDIOMYOPATHY:
Patient was found to have diastolic heart failure and had an
echocardiogram which showed a resting LVOT gradient similar to
previous. Given sepsis her BB/CCB/Lasix were intially held but
BB and Verapamil were restarted prior to discharge. Lasix was
held as patient was not volume overloaded and the patient was
given instructions to discuss restarting of her Lasix at her PCP
[**Name Initial (PRE) **] 3 days from discharge at which time her Lasix can likely be
restarted.
.
# ACUTE RENAL INSUFFICIENCY - No prior documentation of chronic
renal disease; baseline creatinine 0.8-1.0 per outpatient
records. Admitted with hypotension and creatinine responded to
volume resuscitation (admission creatinine 1.8). Likely
pre-renal in the setting of volume depletion/infection. vs.
decreased effective-circulating volume vs. poor forward flow in
the setting of LVOT obstruction. Her creatinine improved and was
0.8 on discharge.
.
# LEFT EYE CONJUNCTIVAL INJECTION, IRRITATION - The pateint had
acute onset of left eye irritation with conjunctival injection.
Ophthalmology consulted and noted left epithelial tear. We
treated with polysporin ointment Q4H and she will continue this
for 7-days without follow-up.
.
# CORONARY ARTERY DISEASE - Patient presented with known CAD;
last cardiac catheterization in [**10/2168**] (Dr. [**Last Name (STitle) **] showing a
right dominant system with no angiographically significant CAD -
the LMCA, LAD, LCX, and RCA were all patent with mild disease.
LVEF 56%. She had undergone stenting of her LAD in [**5-/2168**] of a
70% mid-LAD lesion. She presented with non-specific chest
complaints this admission, which resolved with IV fluid
resuscitation. EKG remained reassuring. No cardiac biomarkers
obtained. We continued Aspirin, Plavix and her statin
medication.
.
# HYPERTENSION - Home regimen includes Atenolol and Verapamil.
These were held given her recent hypotension concerns this
admission. Atenolol 50 mg PO daily was resumed prior to
discharge. Verapamil will be resumed as an outpatient.
.
# DEPRESSION - We continued Amitryptiline 50 mg PO QHS.
.
# GOUT - Exam findings not consistent with acute gout flare. We
avoided Allopurinol given prior hypersensitivity syndrome
(documented in records) and resumed her home colcichine dosing
once her creatinine stabilized.
.
# IgM MONOCLONAL GAMMOPATHY OF UNDETERMINED SIGNIFICANCE - MICU
checked immunoglobulin levels in the setting of suspected sepsis
to see if she was a candidate for IVIG - this admission IgG 846,
IgA 54, IgM 348 - similar to her prior values. She improved
without need for IVIG therapy.
.
# CELIAC DISEASE - Patient was diagnosed 15-years ago and she
has never been compliant with a glute-free diet. She has
occasional flatulence without bloating or diarrhea. She has some
resulting osteoporosis - on calcium and vitamin D
supplementation. Last tTG was 61. Her most recent EGD was in
[**2167**] and was consistent with celiac disease. Will need
outpatient follow-up with her gastroenterologist.
.
# PRIMARY BILIARY CIRRHOSIS, COLONIC ADENOMAS - Diagnosed in
[**2157**] in the setting of abnormal LFTs. Subsequent liver biopsy
demonstrated PBC findings. Has been compliant with Actigal since
that time. Supposed to have yearly AFPs and abdominal U/S for
surveillance. AFP in [**4-/2173**] was normal and her U/S in [**12/2171**] was
stable. She has no symptoms currently. In terms of her colonic
adenomas, her last endoscopy in [**2170**] was stable; repeat to be
performed in [**2175**]. LFTs: AST 47, ALT 32, T-bili 0.4 and normal
Alk-phos this admission. We continued her home dosing of
Ursodiol 900 mg PO QAM, 600 mg PO QHS.
.
TRANSITION OF CARE ISSUES:
1. In terms of her colonic adenomas, her last endoscopy in [**2170**]
was stable - repeat to be performed in [**2175**].
2. PICC line placed and patient will complete 7-day course of IV
Vancomycin for right lower extremity cellulitis concerns.
3. Patient will return home with visiting nurse services and
physical therapy.
4. Patient will continue polysporin eye drops to left eye for
7-days more. No ophthalmology follow-up required.
5. Patient will restart Verapamil on [**2174-1-1**] and her PCP will
determine when she should restart her home Lasix dose.
Medications on Admission:
HOME MEDICATIONS (confirmed with patient)
1. Amitriptyline 40 mg PO daily
2. Atenolol 50 mg PO daily
3. Clopidogrel 75 mg PO daily
4. Colchicine 0.6 mg PO BID
5. Fexofenadine 180 mg PO daily
6. Furosemide 80 mg PO daily
7. Hydrocortisone 2.5% cream rectally applied [**Hospital1 **]
8. Ketoconazole 2% cream applied to skin daily
9. Lactulose 10 gram/15 mL [**11-22**] tablespoons by mouth Q6H PRN
constipation
10. Nystatin 100,000 unit/mL susp - 5 cc by mouth swish and
swallow PO QID
11. Nystatin 100,000 unit/gram powder applied to affected area
PRN TID
12. Oxycodone 10 mg ER PO Q12 hours
13. Simvastatin 40 mg PO daily
14. Ursodiol 900 mg PO Q AM, 600 mg PO QPM
15. Verapamil 120 mg ER PO QHS
16. Zolpidem 10 mg PO QHS PRN insomnia
17. Aspirin 325 mg EC PO daily
18. Biotin 1 mg PO daily
19. Calcium carbonate (2 tabs) 600 mg (1500 mg) PO daily
20. Cholecalciferol-vitamin D3 - [**2161**] units PO daily
21. Cyanocobalamin-B12 (dosage uncertain)
22. Docusate sodium 200 mg PO daily
23. Multivitamin 1 tablet PO daily
Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours) for 7 days: started [**2173-12-27**],
end [**2174-1-2**].
Disp:*5 doses* Refills:*0*
2. Outpatient Lab Work
PICC line dressing change weekly and PRN with cap change.
3. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day.
7. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day.
8. hydrocortisone 2.5 % Cream Sig: One (1) application Rectal
twice a day.
9. ketoconazole 2 % Cream Sig: One (1) application Topical once
a day as needed for rash.
10. lactulose 10 gram/15 mL Solution Sig: [**11-22**] tablespoons PO
every six (6) hours as needed for constipation.
11. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical three times a day as needed for rash.
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO QAM (once
a day (in the morning)).
14. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
15. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day: RESTART on [**2174-11-1**].
16. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
17. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. biotin 1 mg Tablet Sig: One (1) Tablet PO once a day.
19. Calcium 600 600 mg (1,500 mg) Tablet Sig: Two (2) Tablet PO
once a day.
20. cholecalciferol (vitamin D3) 2,000 unit Capsule Sig: One (1)
Capsule PO once a day.
21. cyanocobalamin (vitamin B-12) Oral
22. docusate sodium 100 mg Tablet Sig: Two (2) Tablet PO once a
day.
23. multivitamin Tablet Sig: One (1) Tablet PO once a day.
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
25. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q4H (every 4 hours) for 7 days.
Disp:*1 tube* Refills:*0*
26. Outpatient Lab Work
You should have your electrolytes (chem-10) checked prior to
your appointment with your primary care physician [**Last Name (NamePattern4) **] [**2174-1-4**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Right lower extremity cellulitis
2. Hypotension
.
Secondary Diagnoses:
1. IgM Monoclonal gammopathy of unknown significance
2. Iron deficiency anemia
3. Celiac disease
4. Primary biliary cirrhosis
5. Hypertension
6. Diastolic cardiac dysfunction with left ventricular outflow
tract ostruction
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:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your presumed lower extremity infection and low blood pressure,
which was treated with IV antibiotics and improved. You will
continue with IV antibiotics for a total of 7-days while at
home. You were feeling well prior to discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
START: Vancomycin 1 gram IV every 24-hours for 7-days total
(started [**2173-12-27**] and ending [**2174-1-2**])
START: Bacitracin-polymyxin B 500-10,000 unit/g Ointment to left
eye 6-times daily (every 4 hours) for 7-days (ending [**2174-1-6**])
.
You should RESTART your Verapamil 120 mg ER by mouth daily on
[**2174-1-1**].
.
You should STOP your Lasix medication until discussing the
dosing with your primary care physician in clinic next week.
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
DISCONTINUE: Oxycodone
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Department: [**State **]When: TUESDAY [**2174-1-4**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
.
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2174-3-2**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2174-4-27**] at 1 PM
With: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 0389, 5849, 4280, 2768, 4019, 311 | [
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train_34413 | completed | 0b23731f-4b2d-4f13-a886-dfafaf619cc6 | Medical Text: Admission Date: [**2141-12-1**] Discharge Date:
Date of Birth: [**2071-10-17**] Sex: F
Service:
NO DICTATION
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2141-12-4**] 16:53
T: [**2141-12-4**] 19:54
JOB#: [**Job Number 36788**]
ICD9 Codes: 4111, 4019, 2724 | [
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train_35933 | completed | 9a558635-7026-4f92-a73f-69c5d053445a | Medical Text: Admission Date: [**2204-3-28**] Discharge Date: [**2204-4-3**]
Date of Birth: [**2136-12-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2204-3-28**]: Placement of percutaneous cholecystostomy tube.
History of Present Illness:
Patient is a 67-years-old male was presented in [**Hospital1 **] [**Location (un) 620**] with
c/c abdominal pain on [**2204-3-28**]. CT abdomen revealed likely
cholecystitis vs. cholangitis. Patient was started on
Ceftriaxone and Flagyl and was transferred to [**Hospital1 18**] for further
w/u and management.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Diabetes
4. Peripheral vascular disease
5. CVA with R hemiparesis and right facial palsy
6. Anemia
7. BPH
8. Hypomagnesemia
9. Right femur fracture
10. Depression
Social History:
Resident in skilled nursing facility. Toxic habits not known.
Family History:
Unknown
Physical Exam:
On Discharge:
VS: T 97.4, HR 74, BP 124/66, RR 18, O2 Sat 94%
GEN: Awake and alert, Confused, NAD
HEENT: PERRL, Right gaze preference, right facial palsy
HEART: RRR, no m/r/g
LUNGS: Coarse b/l
ABD: Soft, nontender, right PCT w/dressing c/d/i
EXT: Right hemiparesis, left - normal muscle tone, follows all
commands.
Pertinent Results:
[**2204-3-28**] 06:43AM GLUCOSE-264* LACTATE-3.3* NA+-135 K+-4.5
CL--93* TCO2-26
[**2204-3-28**] 06:30AM GLUCOSE-263* UREA N-22* CREAT-0.8 SODIUM-133
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-27 ANION GAP-17
[**2204-3-28**] 06:30AM ALT(SGPT)-76* AST(SGOT)-94* CK(CPK)-43* ALK
PHOS-134* TOT BILI-1.8*
[**2204-3-28**] 06:30AM LIPASE-16
[**2204-3-28**] 06:30AM WBC-28.2*# RBC-4.52*# HGB-13.9*# HCT-40.0#
MCV-88 MCH-30.6 MCHC-34.7 RDW-13.3
[**2204-3-28**] 06:30AM NEUTS-90.3* LYMPHS-4.1* MONOS-5.4 EOS-0.1
BASOS-0.2
[**2204-3-28**] 06:30AM PLT COUNT-316
[**2204-3-28**] 06:30AM PT-15.1* PTT-26.9 INR(PT)-1.3*
[**2204-3-28**] 07:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-7.0 LEUK-MOD
[**2204-3-28**] 8:41 am MRSA SCREEN Source: Nasal swab.
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2204-3-28**] 7:15 am URINE
URINE CULTURE (Final [**2204-3-29**]): YEAST. >100,000
ORGANISMS/ML..
[**2204-3-30**] BEDSIDE SWALLOWING EVALUATION:
RECOMMENDATIONS:
1. PO diet: ground solids, nectar thick liquids
2. Meds crushed in puree
3. TID oral care
4. Assist with meals as needed to assist with self-feeding and
maintain standard aspiration precautions.
[**2204-4-2**] CHOLANGIOGRAM:
IMPRESSION: Persistent obstruction at the level of the cystic
duct.
Indwelling cholecystostomy tube in adequate position.
Cholelithiasis.
[**2204-3-30**] 06:00AM BLOOD ALT-24 AST-28 AlkPhos-93 TotBili-0.5
[**2204-3-30**] 06:00AM BLOOD WBC-10.1# RBC-2.99* Hgb-9.2* Hct-26.6*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.3 Plt Ct-215
[**2204-3-30**] 06:00AM BLOOD Glucose-81 UreaN-33* Creat-0.6 Na-136
K-3.6 Cl-102 HCO3-26 AnGap-12
Brief Hospital Course:
The patient was admitted in SICU to the General Surgical Service
for evaluation of the aforementioned problem. On [**2204-3-28**], the
patient underwent IR guided placement of cholecystostomy tube
with drainage catheter, which went well without complication
(reader referred to the Procedure Note for details). Patient was
continue on IV antibiotics with Flagyl, Levofloxacin and
Fluconazole. Patient was continue to have IV fluid for hydration
with boluses for low urine output and tachycardia. ON [**3-29**] NG
tube was clamped and patient was advanced to clears with PO home
meds.The patient was hemodynamically stable and was transferred
on the floor. On [**2204-3-30**] patient was neurologically stable,
afebrile with stable vital signs. Swallowing evaluation was
performed and patient was advanced to his baseline of soft
solids and nectar thick liquids with meds crushed in puree once
he is reunited with his dentures. Patient was ordered to have
diagnostic cholangiogram. On [**3-31**] and [**4-1**] patient was afebrile,
with stable vital signs, neurologically stable. On [**2204-4-2**]
patient underwent diagnostic cholangiogram, which revealed
continued cystic duct obstruction, adequate position of the
cholecystostomy tube within the gallbladder, and Cholelithiasis.
On [**2204-4-3**] patient was discharged back in Nursing Home with
instruction to continue antibiotics for another 3 days. Patient
will have a follow up appointment with Dr. [**Last Name (STitle) **] in one month
after discharge.
.
During this hospitalization, patient was neurologically on his
baseline. He is awake and alert, baseline confused. He continue
to have right sided hemiparesis s/t CVA, he follows simple
commands on left side. The patient received subcutaneous
heparin and venodyne boots were used during this stay. The
patient's blood sugar was monitored regularly throughout the
stay; sliding scale insulin was administered when indicated.
Labwork was routinely followed; electrolytes were repleted when
indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a soft
solids diet with nectar thick liquids, voiding without
assistance, and pain was well controlled. The patient was
discharged in his skilled nursing facility with detailed
discharge and follow-up instructions.
Medications on Admission:
1. Novolin (80U qam, 22U qpm, novolin SS)
2. Norvasc 5 mg PO qday
3. Lisinopril 10 mg PO qday
4. Metoprolol 25 mg Po bid
5. ASA 81 mg PO qday
6. Seroquel 25 mg PO qhs and 25 mg PO prn
7. Depakoate 500 mg PO tid
8. Cymbalta 60 mg PO qday
9. Flomax 0.4 mg PO daily
10. Trazadone 25 mg PO prn
11. Percocet 5/325 mg PO prn
12. Combivent nebs prn
13. Senna 2 tabs PO qday
14. Colace 100 mg PO bid
15. MOM 30 ml PO prn
16. Bisacody l0 mg PR prn
17. Fleet enema prn
18. Tylenol prn, MVI
19. MVI qday
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for agitation.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for agitation.
13. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO TID (3 times a day).
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
15. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for groin irritation.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
18. Novolin N 100 unit/mL Suspension Sig: Eighty (80) units
units Subcutaneous qam and 22 units SC qpm.
19. Novolin R 100 unit/mL Solution Sig: [**3-7**] sliding scale units
Injection sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
1. Acute cholecystitis
2. Vascular dementia
3. Right hemiparesis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. Please get plenty of rest,
continue to ambulate several times per day, and drink adequate
amounts of fluids. Avoid lifting weights greater than [**5-21**] lbs
until you follow-up with your surgeon, who will instruct you
further regarding activity restrictions. Avoid driving or
operating heavy machinery while taking pain medications. Please
follow-up with your surgeon and Primary Care Provider (PCP) as
advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
1.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2204-5-11**] 10:00. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]
.
Please call ([**Telephone/Fax (1) 56735**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 31**] in [**2-15**] weeks.
Completed by:[**2204-4-3**]
ICD9 Codes: 4019, 2720, 4439, 2859 | [
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train_35938 | completed | 0d8a3587-8ecc-4a0e-b879-4bbd9889f340 | Medical Text: Admission Date: [**2167-2-23**] Discharge Date: [**2167-2-27**]
Date of Birth: [**2098-7-23**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfonamides
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC: code stroke called at 7:26 pm, at the patient's bedside by
7:30 pm.
HPI: 68 year old left handed woman, with a history of dementia,
HTN, previous breast cancer, who around 6:00 pm became confused.
She had woken up from a nap, and was about to have a cup of tea
with her son, and complained of a headache, and feeling sick.
She
stated to her son that she was having a sinus headache, and had
complained of a headache before she went to bed the previous
night. Her son [**Name (NI) **] [**Name (NI) 15427**] was unable to describe the character
or exact location of the headache. She started to want to vomit
and began to gag. He seated his mother down on the couch, and
she
became more disoriented, so he called 911. By the time the EMS
arrived, she was completely confused as to what they were doing
in the room. A few minutes after they arrived around 6:20 pm,
she
started to slouch in the couch to the left, clench her hands and
started shaking them, her legs were straight out, and she
started
frothing at the mouth with a glazed expression. She was
unresponsive and mute. Prior to this, she had been able to
answer
and understand questions in her normal manner. The episode
lasted
10-15 minutes, and her son thought that she was having a
seizure.
The EMS placed an oxygen mask on her face, and she remained
unresponsive.
Of note she had taken Ibuprofen and Tylenol the previous night
for her headache, and when she woke up in the morning. Her son
had offered to take her to the ER in the morning, but she
mentioned that it was her usual sinus headache, which she saw
her
PCP [**Name Initial (PRE) **]. According to her son, yesterday, they went to [**Name (NI) 15428**] as usual, and she was at her baseline.
By the time that I saw her in the ER, she was already intubated
and paralyzed for airway protection. An ROS was unobtainable.
According to the ER physicians she had a flaccid right sided
paralysis on arrival, which was not appreciable after intubation
and paralysis.
Past Medical History:
Left breast cancer(in records, but son unaware of any history)
asthma vs COPD. Also remote hx of GYN cancer (s/p hysterectomy
in her 20s, further details unknown)
hypertension Benicar stopped a month ago according to her son
mild dementia on formal neuropsych testing(although son states
deficits are no longer mild)-seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
[**2167-11-11**] - Mild intrahepatic biliary dilatation on U/S,
Cholelithiasis w/o son[**Name (NI) 493**] evidence of acute cholecystitis &
she had a UTI.
Past Surgical History:
Tonsillectomy, appendectomy, breast
surgery, hysterectomy, and some sort of bladder neck suspension.
Social History:
SH: Lives in [**Location **] with her son. She goes out of the house
once a day to visit [**Company 2486**]. Capable of ADL's, but does
not
drive or balance a cheque book. Gave up smoking 20 years ago,
prior to that she had been a heavy smoker for 40 years. She does
not drink alcohol or use recreational drugs. She worked in a
cafeteria.
HCP/son [**Name (NI) **] [**Name (NI) 122**] [**Name (NI) 15427**] [**Telephone/Fax (1) 15429**], full code for now
PCP: [**Name10 (NameIs) **] [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2903**] ([**Hospital1 18**]-[**Location (un) **])
Family History:
Her sister died recently of emphysema
Physical Exam:
T-afebrile BP-in the field her systolic BP had been in the 212,
when she arrived in the ER it was 168/121, on propofol it was
140/71 HR-62 RR-16 O2Sat-100% (on vent)FS 177
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
Breast: L breast scar noted, fullness noted in the left upper
outer quadrant.
ext: no edema
Neurologic examination:
Mental status: Intubated and sedated. Received Narcan (2) in the
field, then she was intubated by rapid sequence method
(etomidate+succ), and sedated with propofol (and also given some
versed)
Cranial Nerves:
Pupils 2 mm bilaterally, sluggishly responsive to light.
Corneals
in tact. Dolls head reflex normal. Gag in tact.
Motor:
Withdraws all 4 extremeties to noxious stimulus.
Reflexes:
2 and symmetric throughout, apart from Achilles jerks which are
+1s.
Right toe is upgoing
Coordination & gait could not be assessed
Labs:
pH 7.33 pCO2 44 pO2 484 HCO3 24 BaseXS -2
[**2167-2-23**]
7:33p
Green Top
Na:142
K:3.6
Cl:100
TCO2:17
Glu:191 freeCa:1.16
Lactate:10.7
pH:7.22
Hgb:15.4
CalcHCT:46
Serum tylenol 18.8, rest of serum and Utox unremarkable
Pertinent Results:
[**2167-2-23**] 07:26PM BLOOD WBC-13.1* RBC-4.86 Hgb-14.3 Hct-43.3
MCV-89 MCH-29.5 MCHC-33.1 RDW-12.5 Plt Ct-384
[**2167-2-24**] 02:46AM BLOOD WBC-17.6* RBC-4.31 Hgb-12.5 Hct-37.3
MCV-87 MCH-29.1 MCHC-33.6 RDW-12.9 Plt Ct-270
[**2167-2-23**] 07:26PM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0
[**2167-2-23**] 07:26PM BLOOD Fibrino-547*
[**2167-2-25**] 03:05AM BLOOD ESR-30*
[**2167-2-25**] 03:05AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-142
K-3.1* Cl-109* HCO3-25 AnGap-11
[**2167-2-25**] 03:05AM BLOOD ALT-9 AST-22
[**2167-2-24**] 02:46AM BLOOD CK(CPK)-88
[**2167-2-24**] 02:46AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-2-24**] 02:46AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.6
CT head [**2167-2-23**]
1. Subarachnoid hemorrhage in the left posterior parietal cortex
at the
vertex.
2. No evidence of acute infarct. MRI is more sensitive for the
detection of acute ischemia.
MRI head, MRA / MRV [**2167-2-23**]
1. Extensive areas of signal abnormality with nodular
enhancement throughout
the brain, many of which are centered at the [**Doctor Last Name 352**]-white matter
junction, with
both supra- and infra-tentorial compartments involvement as well
as
involvement of deep [**Doctor Last Name 352**] nuclei.
Differential considerations include an infectious process, which
may be
related to septic emboli (although the lack of more widespread
associated
blood products and infarction is unusual, given the extent of
the
abnormalities), atypical infections such as tuberculosis,
neoplastic processes
such as metastatic disease or lymphoma, toxic metabolic
processes (given deep
[**Doctor Last Name 352**] structure involvement and somewhat bilateral diffuse
symmetric
appearance), as well as other more atypical patterns of emboli,
such as from
an atrial myxoma or bland endocarditis.
2. The left parietal blood products seen on the preceding CT
scan could be
due to septic or bland embolism, or an infectious process.
However, they
could also be indicative of venous ischemia secondary to the
underlying
pathologic process.
3. No evidence of venous sinus thrombosis. While the large
cortical veins
appear patent, MRV is not sensitive for evaluation of cortical
veins.
4. Unremarkable MRAs of the head and neck, without evidence of a
hemodynamically significant stenosis or aneurysm.
5. Areas of increased signal intensity within the left lobe of
thyroid gland,
incompletely characterized on the current study. Correlation
with thyroid
laboratory data and/or ultrasound is recommended.
TTE [**2167-2-24**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. No mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Normal global and regional biventricular systolic
function.
[**2167-2-24**] CXR
FINDINGS: In comparison with the study of [**2-23**], the
endotracheal tube and
nasogastric tube have been removed. There is a vague suggestion
of an area of
increased opacification in the retrocardiac region on the left.
This could
merely reflect atelectasis or crowding of vessels. However, in
view of the
clinical symptoms, the possibility of a developing aspiration
must be
considered. This area should be closely checked on subsequent
radiographs.
On to recent studies, there is suggestion medial displacement of
the stomach,
which could be associated with enlargement of the spleen.
MR HEAD W & W/O CONTRAST Study Date of [**2167-2-26**] 9:53 PM
IMPRESSION: There has been significant interval improvement in
the extent of
T2/FLAIR-signal abnormality throughout the supra- and
infratentorial
compartments with a similar small volume of subarachnoid
hemorrhage, compared
to the prior study. The enhancement at these sites has resolved
completely.
The overall distribution and evolution strongly suggests the
possibility of
underlying PRES, which may be associated with both enhancement
and hemorrhage
in some cases. There is no associated infarct. Other toxic,
neoplastic or
metabolic etiologies as suggested in the report of the previous
exam remain in
the differential diagnosis, though are now considered
significantly less
likely.
Brief Hospital Course:
Ms. [**Known lastname 15427**] is a 68 year old left handed woman, with a history
of dementia, HTN, a remote history of GYN cancer (in her 20s,
s/p hysterectomy, further details unobtainable), presenting with
several day history of headache followed by sudden-onset
confusion, disorientation, and vomiting, with subsequent
10-minute GTC seizure. She was intubated upon arrival to the
emergency department for airway protection and admitted to the
neurology ICU.
.
Hospital course by problem;
.
Neurology; A CT head revealed a right parietal subarachnoid
hemorrhage. An MRI showed extensive areas of signal abnormality
with nodular enhancement throughout the brain on FLAIR and
post-contrast studies. Given the clinical history, it was
thought these may represent transient post-seizure changes. An
MRA and MRV were unremarkable. She was transferred to the
neurology floor.
An MRI with and without contrast was repeated and showed
significant interval improvement in the extent of
T2/FLAIR-signal abnormality throughout the supra- and
infratentorial compartments with a similar small volume of
subarachnoid hemorrhage, compared to the prior study. The
enhancement at these sites has resolved completely. The overall
distribution and evolution strongly suggests the possibility of
underlying PRES, which may be associated with both enhancement
and hemorrhage in some cases. There is no associated infarct.
The patient was started on keppra 750 mg [**Hospital1 **] for seizure
prophylaxis.
.
Respiratory; The patient was extubated on HD#1 and required a
facemask for oxygenation for the following day. She was weaned
to room air.
.
ID; The patient had a Tmax of 101 on HD#1 and has been afebrile
since. She also has a leukocytosis with WBC 17. Blood
cultures, urine cultures, and CXR have showed no sign of
infectious process. The patient has no nuchal rigidity.
.
CV; The patient was monitored on telemetry with no significant
events. A TTE was unremarkable. She was started on simvastatin.
She was instructed to restart Benicar at discharge.
.
Medications on Admission:
AZELASTINE [ASTELIN] - (Prescribed by Other Provider) - 137 mcg
Aerosol, Spray - twice daily
BECLOMETHASONE DIPROPIONATE [QVAR] - (Prescribed by Other
Provider) - 80 mcg Aerosol - twice daily
CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
MEMANTINE [NAMENDA] - 5 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1
Tab(s) by mouth daily
Medications - OTC
DOCUSATE SODIUM [COLACE] - (OTC) - Dosage uncertain
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Benicar HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Memantine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
left parietal subarachnoid hemorrhage
seizure
Discharge Condition:
Mental Status: Awake, Alert, oriented x 2 (her baseline). Able
to say DOW forward
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted after you had a seizure. You were found to a
left-sided parietal subarachnoid hemorrhage in your brain. Your
brain imaging also shows areas of your brain that may have been
affected by high blood pressure in the setting of being off
Benicar for the past month. Repeat imaging prior to your
discharge showed that these areas were improving.
You should re-start Benicar for blood pressure control. We also
have started you on Simvastatin to help with your cholesterol
level. In addition, since you had a seizure you have been
placed on Keppra 750 mg twice daily for seizure prophylaxis.
You should stay on Keppra for at least 6 months.
Please take all medications as prescribed.
Please follow-up with your neurologist, Dr. [**Last Name (STitle) **], as listed
below.
Should you develop any symptoms as listed below or concerning to
you, please call your doctor or go to the emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2167-3-31**] 5:30
Completed by:[**2167-3-7**]
ICD9 Codes: 4019 | [
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train_36001 | completed | 294dc28a-b9ba-4cb6-bb09-bb8ba5014ea6 | Medical Text: Admission Date: [**2130-7-22**] Discharge Date: [**2130-7-28**]
Date of Birth: [**2130-7-22**] Sex: F
Service: Neonatology
HISTORY: [**Known lastname **] [**Known lastname 51634**] is the former 1.84 kg product of a
34-5/7 week gestation pregnancy born to a 32-year-old gravida
2, para 0 woman.
PRENATAL SCREENS: Blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, group beta strep negative.
The pregnancy was notable for dichorionic, diamniotic twins.
The pregnancy was uncomplicated until [**2130-5-27**] when the mother
developed hypertension. On the day of delivery she went into
spontaneousl labor and was allowed to deliver. The infant
was born by spontaneous vaginal delivery under epidural
anesthesia. There was no maternal fever. Rupture of
membranes occurred 16 hours prior to delivery. Apgar scores
were 8 at one minute and 9 at five minutes. The infant was
admitted to the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAMINATION: Examination upon admission to the
Neonatal Intensive Care Unit was weight 1.84 kg, 25th
percentile; length 43 cm, 25th percentile; head circumference
32 cm, 75th percentile. In general she was a pink, alert
baby breathing comfortably in room air. Skin was warm and
dry, color pink, no rashes or lesions. HEENT showed anterior
fontanel soft and flat, prominent molding, sutures mobile,
palate intact. Chest showed breath sounds to be clear and
equal. Cardiovascular had S1 and S2 with normal intensity,
no murmur, well perfused, pulses normal. Abdomen was soft
with normal bowel sounds, no organomegaly. Genitourinary
examination showed a normal female. Anus slightly small and
anteriorly placed, patent. Neurological examination showed
excellent tone, symmetrical movement of upper and lower
extremities.
HOSPITAL COURSE: 1. Respiratory: [**Known lastname **] was in room air
throughout her entire Neonatal Intensive Care Unit admission.
She had no episodes of spontaneous apnea.
2. Cardiovascular: [**Known lastname **] maintained normal heart rates and
blood pressures. During admission there were no
cardiovascular issues.
3. Fluids, electrolytes and nutrition: Enteral feedings were
started on day 1 of life. She has been on all p.o. feedings
during admission. She takes approximately 150-174 cc per kg
per day of Enfamil 20. Recent weight is 1.875 kg with a
length of 43.8 cm and a head circumference of 32 cm.
4. Infectious disease: Due to the preterm labor, [**Known lastname **] was
evaluated for sepsis. A white blood cell count was 12,200
with a differential of 37% polys, 5% bands. A blood culture
was obtained and was no growth at 48 hours.
5. Hematologic: Birth hematocrit was 49.6%. [**Known lastname **] did not
receive any transfusions of blood products.
6. GI: [**Known lastname **] required treatment for unconjugated
hyperbilirubinemia with phototherapy. Her peak serum
bilirubin occurred on day of life two with a total of 9.1/0.3
direct mg per dL. She received phototherapy for
approximately 72 hours. Her rebound bilirubin on [**2130-7-27**]
was 7.8 total with 0.2 direct mg per dL.
7. Neurology: [**Known lastname **] has maintained a normal neurological
examination during admission and there are no neurological
concerns at the time of discharge.
8. Sensory: Hearing screening was performed with automated
auditory brainstem responses. [**Known lastname **] passed in both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The babies were transferred to the
Newborn Nursery on [**2130-7-28**] to board as their mother was
hospitalized for a possible infection.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 51635**], 42nd Avenue,
Suite #400, [**Hospital1 **], [**Numeric Identifier 51636**], phone number [**Telephone/Fax (1) 51637**],
fax number [**Telephone/Fax (1) 51638**]. Appointment is scheduled for Monday
[**2130-7-31**].
CARE AND RECOMMENDATIONS ON DISCHARGE:
1. Ad lib p.o. feeding, Enfamil 20 with iron.
2. No medications.
3. Car seat position screening was performed successfully
with adequate oxygen saturations for 90 minutes.
4. State newborn screen was sent on [**2130-7-25**] and a repeat on
[**2130-7-28**]. No notification of abnormal results to date.
5. No immunizations received to date; plan to receive
hepatitis B vaccine at the pediatrician's office.
6. Immunizations recommended:
A. Synagis RSV prophylaxis should be considered from
[**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the
following three criteria: Born at less than 32 weeks. Born
between 32 and 35 weeks with plans for day care during RSV
season with a smoker in the household or with preschool
siblings.
B. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointment with Dr. [**Last Name (STitle) 51635**] on [**2130-7-31**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34-5/7 weeks gestation.
2. Twin #1 of twin gestation.
3. Suspicion for sepsis ruled out.
4. Unconjugated physiologic hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2130-7-22**] 05:32
T: [**2130-7-28**] 07:05
JOB#: [**Job Number 51639**]
ICD9 Codes: 7742, V290 | [
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train_35249 | completed | e73a7ac9-9fa7-43fb-9268-6ca85e876868 | Medical Text: Admission Date: [**2163-3-4**] Discharge Date: [**2163-3-15**]
Date of Birth: [**2099-7-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
Cornary artery bypass grafts x 5 (LIMA-LAD,
SVG-Dg,SVG-RI,SVG-OM-SCG-PDA) [**3-7**]
History of Present Illness:
This 63 year old white male has known coronary artery disease,
having undergone stents in [**2149**] and [**2153**]. Over the past month
he has had postprandial angina and with exercise. A stress test
was positive and catheterization revealed an 80% left main
stenosis, triple vessel disease and in-stent stenosis at [**Hospital 9956**]. He was transferred for revascularization.
Past Medical History:
coronary artery disease
s/p coronary stents
obesity
insulin dependent diabetes mellitus
hypertension
hypercholesterolemia
s/p herniorraphy
s/p bilateral carpal tunnel release
obstructive sleep apnea
degenerative joint disease
paroxysmal atrial fibrillation
Social History:
Rare ETOH use, nonsmoker
Works as a CPR/BLS instructor
lives with his wife and son
Family History:
noncontributory
Physical Exam:
Admission:
VSS, afebrile
Neuro- intact
HEENT: unremarkable
Lungs- clear.
Cor: SR
Exts- no edema, warm. palplable pulses- sl. diminished
Pertinent Results:
[**2163-3-13**] 01:10PM BLOOD WBC-14.9* RBC-3.47* Hgb-10.6* Hct-30.3*
MCV-87 MCH-30.7 MCHC-35.2* RDW-15.3 Plt Ct-651*
[**2163-3-13**] 01:10PM BLOOD UreaN-22* Creat-0.9
[**2163-3-13**] 06:50AM BLOOD Glucose-70 UreaN-23* Creat-1.0 Na-137
K-4.2 Cl-100 HCO3-29 AnGap-12
[**2163-3-13**] 01:10PM BLOOD WBC-14.9* RBC-3.47* Hgb-10.6* Hct-30.3*
MCV-87 MCH-30.7 MCHC-35.2* RDW-15.3 Plt Ct-651*
[**2163-3-13**] 06:50AM BLOOD Glucose-70 UreaN-23* Creat-1.0 Na-137
K-4.2 Cl-100 HCO3-29 AnGap-12
[**2163-3-13**] 01:10PM BLOOD UreaN-22* Creat-0.9
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 101**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 9957**] (Complete) Done
[**2163-3-7**] at 9:41:55 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2099-7-19**]
Age (years): 63 M Hgt (in): 68
BP (mm Hg): 110/60 Wgt (lb): 220
HR (bpm): 70 BSA (m2): 2.13 m2
Indication: Chest pain. Coronary artery disease. Left
ventricular function. Right ventricular function. Valvular heart
disease. Intraoperative TEE for CABG procedure.
ICD-9 Codes: 786.51, 440.0, 414.8, 424.0
Test Information
Date/Time: [**2163-3-7**] at 09:41 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW4-: Machine: Siemens
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Arch: 2.2 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 50 ms
Mitral Valve - MVA (P [**2-11**] T): 4.4 cm2
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.14
Mitral Valve - E Wave deceleration time: 171 ms 140-250 ms
Findings
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mild symmetric LVH with normal cavity
size and global systolic function (LVEF>55%). Overall normal
LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal aortic arch diameter. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild to
moderate ([**2-11**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS: No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular cavity size and regional/global
systolic function are normal (LVEF >55%). There is mild
symmetric LVH. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is mild to moderate
mitral regurgitation. There is no pericardial effusion.
POST-BYPASS: The patient is in sinus rhythm and on an infusion
of phenylephrine. Biventricular function is preserved. The aorta
is intact. The examination is unchanged.
Dr. [**Last Name (STitle) 914**] was notified in person of the results in the
operating room.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2163-3-7**] 16:40
?????? [**2157**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Following admission he remained stable and he went to the
Operating Room where quintuple bypass grafting was performed.
He tolerated the procedure well and weaned from bypass on
propofol alone. The patient weaned from the ventilator easily
and was extubated. He was begun on beta blockers, diuretics and
transferred to the floor on the first postoperative day.
He was stable from a cardiovascular standpoint, however, his
glucose was extremely elevated and he required transfer to the
ICU for an insulin infusion. Medications were adjusted and he
was able to trnasfer out of the ICU. He briefly had atrial
fibrillation and was begun on Amiodarone with good effect. He
transferred to [**Hospital Ward Name 121**] 6 again on [**3-11**]. Glucoses were adequately
controlled and diuresis was continued.
He had a moderate amount of serosanguinous drainage from the
lower sternotomy wound and the JP site on his left leg. IV
Kefzol was initiated, and drainage minimized. PT worked with
the patient for ambulation and conditioning.
His CPAP nasal device was in use throughout his stay.
Postoperative course was otherwise uneventful. The patient was
discharged home on PO Keflex, as well as an amiodarone taper.
By the time of discharge on POD 4, the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics.
Medications on Admission:
Vytorin 10/40 QD
Toprol XL 200MG/d
Tricor 145mg/D
ASA 325MG/d
Metfromin 1000mg/AM,2000mg/PM
Lantus 100U [**Hospital1 **], Folate 1mg/D
Celebrex 200mg/[**Hospital1 **]
Flexeril 10mg TID prn
Tamsulosin 0.4 mg/D
Humalog SSI
Zyrtec 10mg/D
Cozaar 100mg/D
Zoloft 50mg/D
Discharge Medications:
1. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
2. Influen Tr-Split [**2162**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED) for 1 days.
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
[**Year (4 digits) **]:*28 Tablet(s)* Refills:*0*
4. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
[**Year (4 digits) **]:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
[**Year (4 digits) **]:*60 Capsule(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO daily ().
[**Year (4 digits) **]:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
[**Year (4 digits) **]:*60 Tablet(s)* Refills:*0*
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
[**Year (4 digits) **]:*60 Tablet Sustained Release 24 hr(s)* Refills:*0*
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
[**Year (4 digits) **]:*30 Tablet, Chewable(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 4 weeks.
[**Year (4 digits) **]:*56 Tablet(s)* Refills:*0*
14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days.
[**Year (4 digits) **]:*28 Capsule(s)* Refills:*0*
15. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
[**Year (4 digits) **]:*30 Tablet(s)* Refills:*0*
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
[**Year (4 digits) **]:*7 Tablet(s)* Refills:*0*
17. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day: 100mg twice daily until further instructed by PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*2*
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
19. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: 100 units
Subcutaneous twice a day: 100 units twice daily.
[**Name Initial (NameIs) **]:*qs * Refills:*2*
20. Insulin Lispro 100 unit/mL Insulin Pen Sig: varies
Subcutaneous four times a day: sliding scale.
[**Name Initial (NameIs) **]:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x 4(LIMA-LAD, SVG-Dg, SVG-RI,
SVG-OM, SVG-PDA) [**3-7**]
insulin dependent diabetes mellitus
obesity
hypertension
hypercholesterolemia
s/p carpal tunnel releases
benign prostatic hypertrophy
degenerative joint disease
obstructive sleep apnea
paroxysmal atrial fibrillation
depression
s/p inguinal herniorraphy
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] (for Dr.[**Last Name (STitle) 914**]) on [**3-17**] at [**Hospital3 1280**] Heart
Center([**Telephone/Fax (2) 6256**])
Dr. [**First Name (STitle) 9959**] [**Name (STitle) 9960**] in 2 weeks ([**0-0-**])
Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 1295**] in [**4-13**] weeks
please call for appointments
Completed by:[**2163-3-15**]
ICD9 Codes: 4111, 4019, 2720 | [
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train_40511 | completed | 321c3a84-115a-4dab-a1e8-b50357456d95 | Medical Text: Admission Date: [**2114-6-13**] Discharge Date: [**2114-7-26**]
Date of Birth: [**2045-2-17**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2114-6-13**] open retroperitoneal AAA repair
[**2114-6-13**] exploratory laparotomy, splenectomy
[**2114-6-29**] retroperitoneal exploration, evacuation of hematoma,
bronchoscopy
[**2114-7-17**] tunneled hemodialysis catheter placement
[**2114-7-21**] PEG tube placement
History of Present Illness:
[**Known firstname **] [**Known lastname 41841**] is a 69-year-old patient of Dr. [**Last Name (STitle) 2903**] who presents
for evaluation of an aortic aneurysm recently discovered. She
has a twin sister with both cerebral and abdominal aortic
aneurysm and had treatments. She also has other sisters and
family members with aneurysms. No early ruptures that I was
aware of. Over the last few months, she describes as a beating
sensation in her abdomen. Dr. [**Last Name (STitle) 2903**] examined her and ordered a
CT scan and identified the aneurysm. In addition, she has had
some weight loss about 18 lbs over the last year. It is not
clear why. She has no food fear. She has no pain when she
eats. She does have some depression and thinks as a part of it.
Past Medical History:
PMH: Hypertension, COPD, depression/anxiety, high cholesterol,
chronic renal insufficiency.
PSH: TAH.
Social History:
Alcohol, occasionally. Tobacco, stopped a week ago, smoked a
pack a day for 50 years. She is retired waitress. G2, P2.
Widowed with 2 adult children, grandchildren,
great-grandchildren.
Family History:
unknown
Physical Exam:
She is a thin female in no acute distress. Carotids are 2+
without bruit. Lungs are clear. Heart is regular rate and
rhythm. Neck is supple. Thyroid is without
masses. Neuro is grossly intact.
Peripheral vascular exam: Palpable femoral, popliteal and
dorsalis pedis pulses bilaterally. Palpable radial and brachial
pulses bilaterally.
Pertinent Results:
Hematocrit drop following AAA repair, secondary to splenic lac.
[**2114-6-13**] 08:07PM BLOOD Hct-25.7*
[**2114-6-13**] 08:32PM BLOOD Hct-18.6*#
Rising WBC:
[**2114-6-19**] 02:24AM BLOOD WBC-10.5 RBC-3.69* Hgb-11.0* Hct-32.8*
MCV-89 MCH-29.7 MCHC-33.5 RDW-18.1* Plt Ct-169
[**2114-6-20**] 02:05AM BLOOD WBC-12.0* RBC-3.74* Hgb-11.3* Hct-33.0*
MCV-88 MCH-30.1 MCHC-34.1 RDW-17.8* Plt Ct-209
[**2114-6-21**] 03:00AM BLOOD WBC-14.7* RBC-3.58* Hgb-10.6* Hct-32.3*
MCV-90 MCH-29.5 MCHC-32.7 RDW-17.7* Plt Ct-262
[**2114-6-22**] 02:42AM BLOOD WBC-18.3* RBC-3.62* Hgb-10.6* Hct-32.2*
MCV-89 MCH-29.2 MCHC-32.8 RDW-17.8* Plt Ct-371
[**2114-6-22**] 11:36AM BLOOD WBC-17.7* RBC-3.58* Hgb-10.4* Hct-32.5*
MCV-91 MCH-29.1 MCHC-32.1 RDW-17.7* Plt Ct-371
[**2114-6-23**] 02:56AM BLOOD WBC-21.1* RBC-3.34* Hgb-9.8* Hct-30.2*
MCV-90 MCH-29.4 MCHC-32.6 RDW-17.9* Plt Ct-439
[**2114-6-19**] 2:47 am SPUTUM CULTURE Source: Endotracheal.
**FINAL REPORT [**2114-6-22**]**
GRAM STAIN (Final [**2114-6-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2114-6-22**]):
OROPHARYNGEAL FLORA ABSENT.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
PSEUDOMONAS SPECIES. SPARSE GROWTH. PSEUDOMONAS
ORYZIHABITANS.
sensitivity testing performed by Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PSEUDOMONAS SPECIES
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S S
CEFTAZIDIME----------- <=1 S <=2 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.5 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S <=1 S
MEROPENEM-------------<=0.25 S S
PIPERACILLIN---------- <=8 S
PIPERACILLIN/TAZO----- <=4 S <=8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2114-6-27**] 11:46 am URINE CULTURE Source: Catheter.
**FINAL REPORT [**2114-6-28**]**
URINE CULTURE (Final [**2114-6-28**]):
YEAST. >100,000 ORGANISMS/ML..
Hematocrit drop secondary to retroperitoneal hematoma.
[**2114-6-28**] 12:16PM BLOOD Hct-28.2*
[**2114-6-29**] 12:22AM BLOOD Hct-16.7*
Rising creatinine secondary to ARF.
[**2114-6-13**] 03:08PM BLOOD Glucose-86 UreaN-17 Creat-1.3* Na-138
K-4.5 Cl-114* HCO3-21* AnGap-8
[**2114-6-14**] 03:52PM BLOOD Glucose-84 UreaN-19 Creat-1.6* Na-142
K-4.4 Cl-118* HCO3-21* AnGap-7*
[**2114-6-15**] 03:26AM BLOOD Glucose-124* UreaN-21* Creat-1.7* Na-146*
K-4.0 Cl-116* HCO3-23 AnGap-11
[**2114-6-15**] 09:32PM BLOOD Glucose-100 UreaN-25* Creat-2.1* Na-143
K-4.1 Cl-111* HCO3-24 AnGap-12
[**2114-6-16**] 04:18AM BLOOD Glucose-94 UreaN-28* Creat-2.2* Na-142
K-3.9 Cl-111* HCO3-23 AnGap-12
[**2114-6-17**] 07:51PM BLOOD Glucose-113* UreaN-39* Creat-2.4* Na-141
K-3.9 Cl-112* HCO3-22 AnGap-11
[**2114-6-20**] 02:05AM BLOOD Glucose-120* UreaN-50* Creat-2.6* Na-138
K-4.2 Cl-107 HCO3-22 AnGap-13
[**2114-7-1**] 02:59AM BLOOD Glucose-145* UreaN-101* Creat-2.8* Na-144
Cl-109* HCO3-25
[**2114-7-2**] 03:07AM BLOOD Glucose-97 UreaN-112* Creat-3.0* Na-146*
K-4.0 Cl-110* HCO3-24 AnGap-16
[**2114-7-2**] 05:56PM BLOOD UreaN-118* Creat-3.2* K-4.6
[**2114-7-3**] 01:59AM BLOOD Glucose-140* UreaN-123* Creat-3.3* Na-142
K-4.5 Cl-107 HCO3-22 AnGap-18
[**2114-7-3**] 03:08PM BLOOD UreaN-130* Creat-3.5* K-4.7
[**2114-7-4**] 02:56AM BLOOD Glucose-126* UreaN-137* Creat-3.7* Na-140
K-4.4 Cl-105 HCO3-22 AnGap-17
[**2114-7-5**] 03:14AM BLOOD Glucose-95 UreaN-148* Creat-4.1* Na-138
K-4.4 Cl-103 HCO3-22 AnGap-17
[**2114-7-6**] 04:28AM BLOOD Glucose-96 UreaN-146* Creat-4.3* Na-136
K-4.5 Cl-100 HCO3-21* AnGap-20
[**2114-7-7**] 03:07AM BLOOD Glucose-105 UreaN-149* Creat-4.6* Na-137
K-4.4 Cl-100 HCO3-19* AnGap-22*
[**2114-7-8**] 03:59AM BLOOD Glucose-121* UreaN-151* Creat-5.0* Na-137
K-4.1 Cl-99 HCO3-18* AnGap-24
[**2114-7-8**] 02:33PM BLOOD Glucose-107* UreaN-154* Creat-5.2* Na-135
K-4.3 Cl-97 HCO3-20* AnGap-22
Brief Hospital Course:
On [**6-13**], patient underwent open abdominal aortic aneurysm repair
with Dacron
graft via a retroperitoneal approach. During the procedure, she
had mobilization of her left kidney and spleen over the aorta
and retracted to allow access to the
supraceliac aorta. The case proceeded very smoothly and the
patient was taken to the recovery room and kept intubated.
Initially the patient appeared to be hypovolemic and was given a
combination of fluid and blood and stabilized. She was not on
pressors at the time. Later in the evening, a hematocrit came
back at 25. She was given 2 units of blood and was still very
stable, making urine with no acidosis. However, she became more
distended and the decision was made to return her to the
operating room for exploratory laparotomy. The spleen was found
to have a significant laceration and was thus removed. She had
Cell [**Doctor Last Name **] and multiple transfusions intraoperatively. She was
taken to the ICU afterwards.
On [**6-15**], she began to have bursts of afib with rate up to 140s.
IV heparin, lopressor, and amiodarone were started as per
Cardiology recs. These episodes continued throughout her
hospitalization despite treatment.
Vanco was started on [**6-16**] for wound leakage. Cefepime was added
on [**6-21**] when her WBC rose to 18.3 from 14.7. WBC further
increased to 21 on [**6-23**]. A CT chest/abdomen was performed to
look for a source of infection; none was found. Sputum cultures
drawn [**6-19**] grew Pseudomonas & Klebsiella. Cipro was added on
[**6-25**]. Urine cultures from [**6-27**] grew yeast, and caspofungin was
added.
She was extubated on [**6-26**].
On [**6-27**], the [**Doctor Last Name 406**] drain was removed.
On [**6-29**], patient's Hct dropped from 28.2 to 16.7. She was not
hemodynamically unstable. She underwent a non-contrast CT scan
which revealed a large retroperitoneal hematoma with abdominal
fluid. IV heparin was stopped and she was taken to the
operating room on [**6-30**] for exploration and evacuation of the
hematoma. She also underwent bronchoscopy. Mucous plugging was
noted and lavage was performed. She was then taken to the CSRU.
On [**7-1**], she was extubated and reintubated for CO2 retention.
Caspo was d/c'd on [**7-2**].
On [**7-3**], she underwent ultrasound guided thoracentesis of right
pleural effusion. Cultures were negative.
Nephrology was consulted on [**7-2**] for ARF. A duplex renal
ultrasound showed lack of diastolic flow. Medical diuresis
failed, and she was started on CVVH on [**7-8**].
On [**7-4**], BRBPR was noted. On [**7-5**], her NGT output was
bloody/coffee grounds emesis. GI was consulted. She underwent
EGD on [**7-5**], which showed ulcers in the lower third of the
esophagus and in the fundus, as well as erosion in the stomach.
A PPI was started. Colonoscopy showed an ulcer in the rectum,
and an otherwise normal colon up to the sigmoid. There was poor
visualization of the sigmoid colon.
She was extubated on [**7-6**]. Vanco was d/c'd.
Speech & swallow could not rule out aspiration on [**7-12**]. Dr. [**Name (NI) 45689**] service was consulted to place a PEG, but deferred
until her WBC decreased. Dobhoff tube was placed on [**7-14**].
On [**7-15**] she was transferred to the VICU. Antibiotics were d/c'd
on [**7-16**].
A tunneled cath was placed by IR on [**7-17**] for hemodialysis.
On [**7-19**], she returned to the CSRU for respiratory distress
requiring BiPAP.
PEG was placed on [**7-21**].
She was transferred back to the VICU on [**7-23**].
Cardiology was consulted on [**7-23**] re: anticoagulation for Afib in
the face of recent GI bleed. ASA 325 was recommended.
On [**7-24**], she underwent a repeat bedside swallowing evaluation,
and she was cleared for a thin liquids/pureed solids diet with
continued PEG tube feeds for nutrition.
On [**7-26**], patient was deemed stable for discharge to rehab. Her
Foley was d/c'd. She has minimal urine output. She has
received her post-splenectomy vaccinations. She will continue
on her current medications and hemodialysis. She will
eventually need a colonoscopy, which can be performed an an
outpatient basis.
Medications on Admission:
Zoloft 75', Xanax 0.5''', Toprol XL 50', lisinopril 10',
simvastatin 20'
Discharge Medications:
1. Simvastatin 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY
(Daily).
2. Sertraline 50 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Month/Year (2) **]: [**3-2**]
Puffs Inhalation QID (4 times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (3) **]: One (1) ml
Injection [**Hospital1 **] (2 times a day).
5. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Four (4) ml PO Q6H
(every 6 hours) as needed.
6. Acetylcysteine 10 % (100 mg/mL) Solution [**Hospital1 **]: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed.
7. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical PRN
(as needed).
8. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**11-28**] Sprays Nasal
DAILY (Daily) as needed.
9. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day).
10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Day (2) **]: One (1)
neb Inhalation Q6H (every 6 hours).
11. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
Inhalation Q6H (every 6 hours).
12. Morphine 2 mg/mL Syringe [**Month/Day (2) **]: 0.5 ml Injection Q4H (every 4
hours) as needed.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day).
15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed.
16. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
17. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
18. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
19. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
20. Ativan 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a
day as needed.
21. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Two (2) ml
Injection Q8H (every 8 hours) as needed for nausea.
22. regular insulin sliding scale
fingersticks qAC & qHS
Glucose: Regular Insulin
0-50 mg/dL [**11-28**] amp D50
51-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
> 320 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Hospital @ [**Doctor Last Name 1263**]
Discharge Diagnosis:
AAA s/p repair, splenic laceration s/p splenectomy,
retroperitoneal hematoma s/p evacuation, dysphagia s/p PEG tube,
HTN, COPD, depression, hypercholesterolemia, renal failure on
hemodialysis
Discharge Condition:
fair
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-4**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**12-30**]
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
?????? You should get up every day, get dressed and walk, gradually
increasing 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 (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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2114-8-28**] 10:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1241**] Follow-up appointment
should be in 2 weeks
Completed by:[**2114-7-26**]
ICD9 Codes: 5849, 5859, 2851, 2720 | [
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train_33704 | completed | 28e46cb8-76c1-4e99-a0be-b53888414432 | Medical Text: Admission Date: [**2116-7-15**] Discharge Date: [**2116-7-15**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
male with a history of CLL diagnosed five years ago, status
post fludarabine times one year complicated by AIHA, then
switched to chlorambucil plus prednisone with the former
discontinued secondary to decreasing platelets in [**2116-6-13**].
The patient presented to [**Hospital6 8283**] emergency
room on Wednesday with complaints of nausea and vomiting
times one and diarrhea times three. No blood noted in emesis
or stool. The patient reported bleeding from pimple on
forehead, otherwise not noted to have any overt bleeding
sources. At [**Hospital6 8283**] his hematocrit was
24, platelets [**2112**]. Coags were normal. D-dimer positive.
Last CBC taken at that hospital on [**2116-7-6**], revealed
hematocrit of 31 and platelets of 101,000. In the emergency
room he was given intravenous fluids, Solu-Medrol 200 mg IV,
suspecting ITP versus leukemic transformation and
levofloxacin. He was transferred to [**Hospital1 190**] emergency room via ambulance for further
management. In [**Hospital3 **] E.R. the patient was seen by the
bone marrow transplant service. Peripheral blood smear
revealed a single, normal appearing platelet without clumps
or schistocytes. In the emergency room he had bright red
blood per rectum times two and significant hematuria
complicated by clot retention and difficult Foley placement
necessitating urology consult. A 14 French coude was placed.
Repeat labs confirmed hematocrit of 24 and platelets of [**2112**].
He was given one unit of packed red blood cells and a six
pack of platelets as well as IVIG for presumed ITP and
transferred to the Fennard ICU. The patient was
hemodynamically stable throughout the E.R. course.
PAST MEDICAL HISTORY: CLL. Primary oncologist in [**Hospital3 **] is Dr. [**Last Name (STitle) 55734**].
BPH status post TURP.
Hypercholesterolemia.
MEDICATIONS ON ADMISSION: Prednisone 4 mg p.o. q.d.,
acyclovir 400 mg p.o. b.i.d., Lipitor, aspirin, Hytrin,
Protonix 40 mg p.o. q.d., folate 3 mg p.o. q.d., Bactrim
double strength one tab b.i.d. Monday, Wednesday, Friday.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with wife on [**Hospital3 4298**].
Retired college administrator and [**Male First Name (un) **]. No children. Prior
smoker 20 pack years, quit 20 years ago. Rare alcohol use.
FAMILY HISTORY: No oncologic family history.
PHYSICAL EXAMINATION: On admission temperature 98.6, t-max
99.1, heart rate 104, blood pressure 143/67, 100 percent on 2
liters. In general, he was a very pleasant man in no
apparent distress. HEENT PERRL, sclerae anicteric, moist
mucous membranes, no mucosal bleeding or petechiae. Neck no
LAD, no JVD, no thyromegaly, no masses. Lungs clear to
auscultation bilaterally. CV regular rate and rhythm, normal
S1, S2, no murmurs, rubs or gallops appreciated. Abdomen
soft, significantly distended, patient claimed baseline,
moderately tympanitic, nontender, no hepatomegaly,
hyperactive bowel sounds. Extremities trace pitting edema,
warm, 1 plus distal pulses. Skin petechiae on upper and
lower extremities and abdomen.
EKG normal sinus rhythm, normal axis, first degree AV block,
3 with Q wave and inverted T wave. Chest x-ray from [**Hospital3 **], AP and lateral, appeared within normal limits, no
infiltrates, cardiomegaly or lymphadenopathy. Labs on
admission white count 10.8, hematocrit 23.7, platelets less
than 5, MCV 103. INR 1.2. Creatinine 1.4. LFTs were within
normal limits. Amylase and lipase were normal. D-dimer
elevated at 10, fibrinogen 280.
ASSESSMENT: The patient is a 74 year old male with a history
of CLL presenting with severe thrombocytopenia and bleeding.
HOSPITAL COURSE: Thrombocytopenia. Initially the patient
was transferred to the ICU where he remained until [**7-24**]
when he was transferred to the bone marrow unit. Early
differential diagnosis for thrombocytopenia included
medication or chemo effect, ITP, TTP, HUS, sequestration or
viral infection. The patient was initially given IVIG 1 gm
per kg and was maintained on Solu-Medrol 200 mg q.d. He was
given a four day course of Decadron 40 mg q.d. The patient
had a bone marrow biopsy which showed the presence of sparse
megakaryocytes which looked normal, but low in number. The
patient was treated with Rituxan and also with vincristine.
CT scan showed a normal sized spleen with a small infarct.
The patient was seen in consultation by surgery for the
possibility of splenectomy, but at the time of dictation
splenectomy is low on the list of possibilities, given the
lack of response to IVIG, steroids and the surgical risks,
given his platelet count. At the time of dictation the
patient's platelet count has slightly improved. It is
running between 50 and 85 and he requires one to two bags of
platelets per day, which is improved compared with the three
bags of platelets he was requiring at the beginning of his
hospitalization.
Anemia. The patient was initially transfused with a goal
hematocrit of 25. He initially had bright red blood per
rectum and maroon stools. The source of the GI bleeding is
unknown. At this time he has not had a colonoscopy, but once
his platelet count improves and he is discharged, he should
be seen by gastroenterology in followup for further workup of
his GI bleeding. He also had hematuria associated with low
platelet count. He was seen by urology several times in
consultation, initially in the E.R. to place a Foley after he
developed urinary retention. For several days he had
hematuria associated with his low platelet count. Once the
Foley was changed and the counts were kept at a level above
50, the hematuria resolved and at the time of dictation he
has had clear urine without red blood cells for five days.
The plan will be to continue Proscar for an additional three
days and try to have a voiding trial and remove the Foley.
CLL. The patient was treated with Rituxan once and the plan
is to continue to treat him weekly during his
hospitalization. See subsequent dictation for further
information regarding this issue.
Acute renal failure. The patient initially presented an
elevated creatinine, but improved upon hydration. At the
time of dictation creatinine is in the normal range between
0.8 and 1.
Hyperglycemia. The patient was placed on an insulin sliding
scale while receiving high dose steroids.
Hypercholesterolemia. The patient's statin drug has been
held while in the hospital. Once his platelet count returns
to normal, he can be restarted on this medication.
Further dictation of the [**Hospital 228**] hospital course as well as
discharge status, discharge condition, discharge medications
and followup will be dictated by the next intern taking over
the service.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-699
Dictated By:[**Last Name (NamePattern1) 19183**]
MEDQUIST36
D: [**2116-8-4**] 13:46:29
T: [**2116-8-4**] 14:38:11
Job#: [**Job Number 55735**]
ICD9 Codes: 5789, 5849 | [
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train_35052 | completed | 527e4154-57c3-46e6-bc94-4faaa815f4ce | Medical Text: Admission Date: [**2145-2-10**] Discharge Date: [**2145-2-19**]
Service: General Surgery
ADMISSION DIAGNOSIS: Partial small bowel obstruction.
DISCHARGE DIAGNOSIS: Partial small bowel obstruction.
PROCEDURES DURING ADMISSION: Exploratory laparotomy with
lysis of adhesions.
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
female who presents to the emergency room with 24 hours of
abdominal pain on the right side, no radiation, no nausea but
emesis x 7 with no flatus since [**65**] hours prior to admission.
PAST MEDICAL HISTORY: 1. Myocardial infarction in [**2136**]. 2.
History of small bowel obstruction status post lysis of
adhesions. 3. Multiple endocrine neoplasia type IIa status
post bilateral adrenalectomy for pheochromocytoma and
thyroidectomy with radiation therapy for thyroid cancer. 4.
Status post cholecystectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: 1. Florinef 100 mcg once a day.
2. Prednisone 7.5 mg in the morning, 5 in the evening. 3.
Levoxyl 0.15 mg once a day. 4. Lopressor 150 mg twice a day.
5. Aspirin 325 mg once a day. 6. Celexa 10 mg once a day.
7. Oxycodone 5 mg every 4-6 hours as needed. 8. Lorazepam 5
mg once a day as needed. 9. Lomotil 2 tablets four times a
day. 10. Opium 10 drops t.i.d. 11. Prilosec 20 mg two times
a day. 12. Morphine as needed. 13. Urimar 15 mg once a day.
PHYSICAL EXAMINATION: Temperature 97.1, heart rate 99, blood
pressure 150/44, respiratory rate 20, saturating 90% on room
air. She was alert, uncomfortable, heart was regular. Her
abdomen was soft, mildly distended with tenderness on the
right side and also in the left lower quadrant. Her rectal
examination was heme negative.
LABORATORY DATA: White count 13, hematocrit 36, bicarbonate
22, liver function tests normal. Abdominal ultrasound was
normal. Common bile duct was 8 mm. KUB had positive
air-fluid levels.
HOSPITAL COURSE: The patient was admitted on [**2145-2-10**]. CAT
scan was obtained which revealed a transition point. The
patient continued to have a large amount of pain and given
the fact that she was on steroids, she was taken to the
intensive care unit, hydrated and then taken emergently to
the operating room for an exploratory laparotomy. The
patient's operation went without complications. She
underwent an exploratory laparotomy with lysis of adhesions
on [**2145-2-10**]. Of note, postoperatively the patient went into
atrial fibrillation. A cardiology consultation was obtained.
She was started on beta blockade. Her heart rate was
controlled with diltiazem as well. She was given stress dose
steroids and started on a taper subsequently. She was also
given perioperative antibiotics. Her heart rate was
adequately controlled and the patient was transferred to the
floor. An endocrine consultation was obtained as well. She
was restarted on her Florinef. Given the fact that the
patient was in and out of atrial fibrillation it was decided
that she would be anticoagulated and that she would be placed
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor when she went home.
Her postoperative course was otherwise uneventful. Her bowel
function returned and she began to have diarrhea again which
is her baseline. She was started back on her Lomotil. She
was kept on 15 b.i.d. of prednisone given the stress of the
surgery and the fact that endocrine felt that this was an
appropriate dose. Of note, her INR did rise fast and was 4.8
on [**2145-2-18**]. Her Coumadin was held. On [**2145-2-19**] her INR was
3.3. The patient was doing well, tolerating a regular diet,
ambulating and it was decided that she would be discharged
home.
DISCHARGE MEDICATIONS:
1. Coumadin to be dosed daily with results called to Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 250**].
2. Lopressor 50 mg p.o. b.i.d.
3. Amiodarone 400 mg p.o. b.i.d. until [**2145-2-20**] and then 400
mg p.o. q.d. until [**2145-2-25**] and then 200 mg p.o. q.d.
ongoing.
4. Florinef 100 mcg p.o. q.d.
5. Levoxyl 0.15 mg p.o. q.d.
6. Lorazepam 5 mg q.h.s. p.r.n.
7. Celexa 10 mg p.o. q.d.
8. Percocet 1-2 tablets p.o. q. 4-6 hours p.r.n.
9. Lomotil 2 tablets p.o. q.i.d.
10. Prednisone 15 mg p.o. b.i.d.
DISCHARGE INSTRUCTIONS:
1. Daily INR checks with results called to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 250**] with a goal INR of [**1-11**].
2. [**Doctor Last Name **] of Hearts monitor.
3. Blood pressure checks.
4. Follow up with Dr. [**Last Name (STitle) **], call for an appointment.
5. Follow up with Dr. [**Last Name (STitle) 73**] regarding her atrial
fibrillation.
6. Follow up with Dr. [**Last Name (STitle) 13059**], her endocrine specialist,
regarding steroid taper.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2145-2-19**] 09:59
T: [**2145-2-19**] 10:29
JOB#: [**Job Number 103744**]
ICD9 Codes: 9971 | [
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train_33610 | completed | 9252a809-fc07-470d-a5cb-1816243d33d4 | Medical Text: Admission Date: [**2142-8-20**] Discharge Date: [**2142-9-11**]
Date of Birth: [**2072-1-13**] Sex: M
Service:
ADDENDUM: His discharge laboratory studies include a white
count of 5.7, hematocrit 32.1, platelet count 254,000, sodium
140, potassium 4.2, chloride 106, CO2 28, BUN 21, creatinine
1.6, glucose 106.
He is also being discharged on 40 of NPH Insulin every
morning and an insulin sliding scale, of which a copy will be
attached to the discharge summary.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 31272**]
MEDQUIST36
D: [**2142-9-11**] 09:05
T: [**2142-9-11**] 09:30
JOB#: [**Job Number 92755**]
ICD9 Codes: 4111, 2762, 4280, 7907 | [
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train_42819 | completed | f2af34ad-76a8-492d-afd5-50efa0ed60e1 | Medical Text: Admission Date: [**2116-2-12**] Discharge Date: [**2116-3-16**]
Date of Birth: [**2070-10-2**] Sex: F
Service: MICU
CHIEF COMPLAINT: Pneumonia/delirium.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
female with a history of Hepatitis C, low grade lymphoma,
major depression and poly-substance abuse, who was admitted
to [**Hospital1 3494**] Intensive Care Unit on [**2-10**], with a
heroin and benzodiazepine overdose, as well as multi-lobar
pneumonia. The patient was initially treated in [**Hospital1 3494**]
Intensive Care Unit with Gatifloxacin and Ceftriaxone until
the sputum came back positive for Moraxella catarrhalis. She
clinically improved from a respiratory standpoint on
intravenous antibiotics. She was on a Buprenorphine taper
for opiate withdrawal, however, she continued to be agitated
and delirious on Haldol. Her transfer to [**Hospital1 346**] was requested per her son, since
patient received all of her medical care at [**Hospital1 346**].
Prior to transfer, the patient received 3 mg of Haldol. On
arrival to the Intensive Care Unit, the patient was minimally
responsive to sternal rub. She was in significant
respiratory distress using accessory muscles, breathing 45
times per minute, with a temperature of 103.8 F., and
saturation of 99% on non-rebreather mask.
PAST MEDICAL HISTORY:
1. Hepatitis C, Genotype 1B. Liver biopsy in [**2112**] showed
chronic Hepatitis, Grade II inflammation, Stage II fibrosis.
She received Rebetron therapy for six months in [**2114-1-23**], and discontinued secondary to the depression. She
received Interferon and Ribavirin combination in [**2115-1-24**]. Her last HCV viral load was 76,800 in [**2115-12-24**].
2. Low-grade lymphoma with IgM gammopathy diagnosed in [**2112**].
3. Intravenous drug use.
4. Poly-substance abuse (heroin, cocaine, benzodiazepines).
5. Major depression.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Motrin 400 q. eight p.r.n.
2. Tequin 400 mg intravenous q. day.
3. Rocephin two grams q. 24 hours.
4. Buprenex 0.3 mg intramuscularly q. eight.
5. Gatifloxacin 200 intravenously.
6. Ceftriaxone 1 gram q. 24 hours on [**2-12**].
7. Haldol 2.5 mg q. one hour.
8. Lactulose 30 p.o. twice a day.
SOCIAL HISTORY: Access intravenous drug abuse. The rest
unavailable.
FAMILY HISTORY: Unavailable.
PHYSICAL EXAMINATION: Temperature 103.8 F.; heart rate 83;
blood pressure 113/51; respiratory rate 45, saturation 99% on
100% non-rebreather mask. Generally, the patient was in
respiratory distress with visible accessory muscle use.
HEENT: Pupils were reactive, 3 to 2.5 mm bilaterally. The
patient was not tracking. Her mucous membranes were dry.
Neck was slightly rigid. Heart was regular rate and rhythm.
Lungs had diffuse wheeze and rhonchi. Abdomen showed healed
low midline scar, good bowel sounds, slight distention, no
rebound or guarding. Extremities showed no edema, two plus
distal pulses.
LABORATORY: On admission from the outside hospital: White
blood cell count 7.0, hematocrit 28.5, platelet count 110.
Chem-7, sodium 148, potassium 4.0, chloride 126, bicarbonate
20, BUN 26, creatinine 1.1, glucose 116. ALT 48, AST 74,
total bilirubin 0.9. Calcium 8.0, PTT 30.5, INR 1.1.
CK 505, 371, 157, negative troponin and negative MB.
Toxicology Screen positive for opiates, cocaine and
benzodiazepines.
Microbiology: Blood cultures negative at 24 hours. Sputum
culture positive for Moraxella catarrhalis. Urine culture
negative.
Arterial blood gas on admission 7.3/48/285.
Chest x-ray on admission from [**Hospital3 **] showing
bilateral infiltrate and left sided small pleural effusion.
HOSPITAL COURSE: During this hospitalization, the patient's
issues included:
1. Hypercarbic respiratory failure: On admission, the
patient's clinical status was significantly worse than in the
outside hospital discharge. Her hypercarbic respiratory
failure was felt to be likely due to the pneumonia. Since
the decompensation was somewhat rapid, it was felt to be due
to new aspiration. The patient was intubated on admission.
She was started on antibiotics and received a full course of
21 days of Zosyn and Levofloxacin. The patient was extubated
on [**2116-2-27**].
2. Lack of gag reflex: Upon extubation, the patient
persisted with significant amounts of secretions that
required frequent suctioning. She was noted to have an
absent gag reflex. CT scan of her brain was obtained which
revealed no stroke. Formal video swallow evaluation revealed
that the patient is aspirating all types of food. After
extensive discussions with son and the patient, the patient
decided to proceed with a PEG tube which was placed by
Interventional Radiology on [**2116-3-11**]. The patient was
changed from Resporal to Ultracal tube feeds to provide
additional nutritional support.
3. Delirium: On admission, the patient's mental status was
severely depressed and she persisted being agitated. On
admission, a head CT scan was performed and revealed no
structural lesions. An lumbar puncture was performed looking
for infection or hemorrhage causing her delirium, however the
cerebrospinal fluid fluids did not indicate either hemorrhage
nor infection. Through the initial part of her
hospitalization, while vented, the patient was sedated with
benzodiazepines and Fentanyl. Following her extubation, the
patient's Fentanyl and Ativan were weaned slowly. When
attempting to transition the patient from a Fentanyl drip to
a patch, significant withdrawal symptoms were observed and
the patient was continued on a slow Fentanyl drip taper. She
was able to successfully come off of the Fentanyl drip and
her Valium was discontinued. Her mental status continued to
improve.
4. Multi-lobar pneumonia, fungemia: For the last three days
of her 21-day course of antibiotics, the patient persisted to
spike fevers to 102.0 F. With each fever spike, cultures
were obtained, and the blood cultures from [**3-10**], grew yeast
in one out of four bottles. The patient was started on
Fluconazole with resolution of her fevers. At that time, her
PICC line was discontinued and peripheral access obtained.
On [**3-16**], the patient was transferred to the Floor. Her
care was taken over by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], who will dictate the
remainder of the discharge summary.
[**Last Name (LF) **],[**Name8 (MD) **] M.D.12-852
Dictated By:[**Last Name (NamePattern1) 1762**]
MEDQUIST36
D: [**2116-3-16**] 14:32
T: [**2116-3-17**] 12:30
JOB#: [**Job Number 16661**]
ICD9 Codes: 5070, 5119 | [
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train_50621 | completed | 6a86df10-201b-4f11-9076-4c860b891660 | Age: 19
Gender: Female
Blood Type: O-
Medical Condition: Cancer
Date of Admission: 2023-10-26
Doctor: Jennifer Miller
Hospital: Inc Cannon
Insurance Provider: Cigna
Billing Amount: 50437.74621614325
Room Number: 108
Admission Type: Elective
Discharge Date: 2023-11-16
Medication: Ibuprofen
Test Results: Inconclusive | [
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train_50638 | completed | b966db16-03d2-408a-b32f-060cf17ba139 | Age: 76
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Date of Admission: 2021-02-25
Doctor: Patricia Wagner
Hospital: Best-Ramsey
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Room Number: 455
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train_50651 | completed | e50a41dd-859e-44c5-831b-1d75f489e4ab | Age: 34
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Blood Type: B-
Medical Condition: Arthritis
Date of Admission: 2019-06-18
Doctor: Blake Pope
Hospital: Jimenez, Green and Wright
Insurance Provider: Cigna
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Room Number: 460
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train_50669 | completed | f0b44c3d-27bd-4a7a-9bb8-6518ec9957ff | Age: 40
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Medical Condition: Arthritis
Date of Admission: 2023-02-02
Doctor: Curtis Li
Hospital: Bailey-Buckley
Insurance Provider: Aetna
Billing Amount: 1779.4729585360017
Room Number: 381
Admission Type: Emergency
Discharge Date: 2023-02-08
Medication: Ibuprofen
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train_50687 | completed | 60420dde-41ca-4507-bdce-fd01ba1724ed | Age: 26
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Medical Condition: Hypertension
Date of Admission: 2021-09-30
Doctor: Michelle Simmons
Hospital: Stephens Group
Insurance Provider: Medicare
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Room Number: 151
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train_16052 | completed | 785ae0a6-e742-496e-8545-b13dfecd61a2 | Medical Text: Admission Date: [**2103-4-24**] Discharge Date: [**2103-4-26**]
Date of Birth: Sex:
Service:
HISTORY: This was a 37-year-old man who while riding a
bicycle was struck by a motorcycle in [**Hospital3 **]. He was
emergently transferred here by helicopter. Upon arrival, he
was intubated and unresponsive. He appeared hemodynamically
stable. He had an open tibial and fibular fracture with
probable dislocation of the left knee. And he had no palpable
pulses at the ankle.
PAST MEDICAL HISTORY: Unremarkable.
HOSPITAL COURSE: The patient underwent a diagnostic
peritoneal lavage which was negative. He was then brought to
the CT scanner. The CT scan at admission on [**4-24**]
demonstrated diffuse intraparenchymal hemorrhage with a
moderate amount of swelling. A CT scan of the chest
demonstrated a possible tear of the descending thoracic
aorta. He had bilateral pneumothoraces and mediastinal blood.
There was no obvious intraperitoneal injury. He had both left
and right-sided pubic ramus fractures and a left iliac pelvic
fracture. He had a left femoral head dislocation. Further
examination demonstrated a left open elbow fracture and a
fracture of the left proximal phalanx of the hand.
It was decided to bring him to the operating room for
relocation of the hip, on-table angiography, and possible
vascular reconstruction of the lower leg. On the day of
admission, he underwent successful operative relocation of
the hip. Dr. [**Last Name (STitle) **] [**Location (un) **], of orthopedics, then irrigated the
left open elbow injury. He placed an external fixator on the
left tibial-fibular fracture. The hand fracture was reduced.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 1391**] of vascular surgery then
performed a left above knee popliteal-to-posterior tibial
saphenous bypass graft. The patient was then returned to the
intensive care unit.
The following day, a repeat head CT showed progression of his
intracerebral hemorrhage with marked edema and subfalcine
herniation. After discussion with the family, it was elected
to make him comfort measures only. Accordingly, he expired on
the 3rd hospital day, [**4-26**].
DISPOSITION: Deceased.
CONDITION ON DISCHARGE: Deceased.
[**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) **], [**MD Number(1) 17554**]
Dictated By:[**Last Name (NamePattern4) 17555**]
MEDQUIST36
D: [**2103-12-25**] 18:41:04
T: [**2103-12-26**] 04:21:52
Job#: [**Job Number **]
ICD9 Codes: 2851 | [
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train_717 | completed | 75e56c2c-88cb-4dc2-893d-a02165484dd1 | Medical Text: Admission Date: [**2144-10-16**] Discharge Date: [**2144-11-18**]
Date of Birth: [**2144-10-16**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 9434**] is a 29-2/7
weeks gestational age male twin born at 1305 gm to a 28-year-
old G1P0 mother with the following prenatal labs. Blood type
O negative, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, GC/C
negative.
This twin diamniotic-dichorionic pregnancy was spontaneously
conceived. No complications other than the mother developed
cervical shortening and was treated with betamethasone on
[**2144-10-2**]. She was transferred to [**Hospital6 2561**] on
the day prior to delivery with preterm labor and further
cervical changes. She was subsequently transferred to [**Hospital6 1760**] for further care. Spontaneous
rupture of membranes occurred three hours prior to delivery.
Delivery was by cesarean section secondary to fetal breech
position. The baby emerged with reduced tone and minimal
respiratory effort. The patient was treated with stimulation
and facial CPAP with prompt resolution of irregular
respirations. Apgars were seven and eight at one and five
minutes. The patient was transferred to the Neonatal
Intensive Care Unit for further management.
PHYSICAL EXAMINATION: On presentation, vital signs showed a
temperature of 97.3, heart rate 164, respiratory rate 50, O2
saturation 95 percent on room air, blood pressure 34/16 with
a mean of 29, weight is 1305 gm, length is 42 cm, head
circumference 27.5 cm. General: Preterm male in radiant
warmer, no apparent distress. HEENT: AFOS, OP clear, palate
intact, red reflex intact bilaterally. Neck: Supple, no
crepitus. Respiratory: Clear to auscultation bilaterally,
good air entry, mild intermittent retractions. Cardiac:
Regular rate and rhythm, S1-S2 normal, no murmur. Abdomen:
Soft, nondistended, no bowel sounds, no hepatosplenomegaly,
anus patent. Genitourinary: Normal male genitalia, descended
bilaterally. Extremities: Well perfused bilaterally, femoral
pulses two plus bilaterally. No cyanosis or edema. Spine:
Intact, no dimpling, no Ortolani or Barlow sign is present.
Neurological: Spontaneous MAE, appropriate tone on exam.
Motor - normal suck, palmar and plantar grasp intact.
HOSPITAL COURSE: Respiratory: Upon arrival to the Neonatal
Intensive Care Unit, the patient exhibited irregular
respirations as well as poor spontaneous respiratory effort
and was intubated. By day of life number three, the patient
was extubated to CPAP plus five and remained on CPAP until
hospital day number six, [**2144-10-22**]. On the next day,
hospital day number seven, the patient was transitioned to
room air and remained so until hospital day fourteen at which
time, he was placed on nasal cannula 21 percent on varying
flows of O2 from 100-200 cc. The patient was placed on nasal
cannula O2 at this time for increased apnea of prematurity.
The patient was weaned off nasal cannula by [**2144-11-10**] and
has remained so until the date of interim discharge summary.
The patient exhibited apnea of prematurity by day of life
number three at which point he was loaded with caffeine
citrate. Caffeine citrate was continued until [**2144-11-11**] at
which point it was discontinued.
Cardiovascular: This patient remained cardiovascularly
stable throughout his hospital course. Secondary to a murmur
heard on day of life number two, the patient received a
cardiac echocardiogram which revealed a small ventricular
septal defect, as well as a small patent ductus arteriosus.
In addition, a small patent foramen ovale was detected with
bidirectional flow present.
Fluids, electrolytes and nutrition: The patient was NPO on
day of life number one at 80 cc/kg/day of parenteral
nutrition. The patient was started on enteral feeds on day of
life number four and was quickly increased to full feeds of
150 cc/kg/day by day of life number ten. Currently at the
time of this interim summary, the patient is on breast milk
32 kilocalories per ounce and 150 cc/kg/day PO/PG.
Hematology: The patient's initial CBC was benign with a
white blood cell count of 5.5, hematocrit of 50.1, platelets
231, differential white count of 27 polycytes, 58
lymphocytes. The patient was placed on ampicillin and
gentamycin secondary to maternal sepsis risk factors and
continued on antibiotics until 48 hours at which point they
were discontinued secondary to negative blood cultures. The
patient had no other infectious disease issues during his
hospitalization.
The patient's bilirubin on day of life number two was 8.6
mg/dl at which point phototherapy was initiated until day of
life number six. The patient's bilirubin dropped to 4.3 mg/dl
at which point phototherapy was discontinued.
Neurologic: The patient remained neurologically stable
throughout his hospital course.
CARE/RECOMMENDATIONS: At the time of interim summary, breast
milk 30 kilocalories per ounce at 150 cc/kg/day. Medications
include ferrous sulfate and vitamin E. State newborn
screening sent. No immunizations administered.
DISCHARGE DIAGNOSES: Prematurity at 29-2/7 weeks gestational
age.
Respiratory distress, resolved.
Hyperbilirubinemia, resolved.
Immature feeding.
Small ventricular septal defect, small patent ductus
arteriosus.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 56932**]
MEDQUIST36
D: [**2144-11-18**] 14:27:27
T: [**2144-11-18**] 15:09:53
Job#: [**Job Number 59620**]
ICD9 Codes: 769, 7742, V290, V053 | [
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train_2335 | completed | a9b42b44-400f-4056-ba58-e53f0a40aa72 | Medical Text: Admission Date: [**2126-5-8**] Discharge Date: [**2126-5-22**]
Date of Birth: [**2126-5-8**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 6930**], twin number two, delivered
at 31-5/7 weeks gestation, weighing 1,525 grams, was admitted
to the intensive care nursery for management of prematurity.
The mother is a 31-year-old gravida 2, para 0, now 2 woman
with conception by in [**Last Name (un) 5153**] fertilization. Estimated date of
delivery was [**2126-7-5**]. Prenatal screens included blood type
A+, antibody screen negative, RPR nonreactive, rubella
immune, hepatitis B surface antigen negative, and group B
Streptococcus unknown. The pregnancy was complicated by a
shortened cervix and preterm labor with admission to [**Hospital1 1444**] about one month prior to
delivery for preterm labor. She was treated with bedrest,
terbutaline and received betamethasone. On the day of
delivery, labor progressed despite tocolysis, with delivery
by cesarean section due to breech position of this twin. The
mother had no fever, did not receive antibiotics prior to
delivery. Membranes were ruptured at delivery. This twin
emerged with spontaneously cry and received free-flow oxygen
with Apgar scores of 7 at one minute and 9 at five minutes.
PHYSICAL EXAMINATION: Admission weight was 1,525 grams (50th
percentile), length 40 cm (30th percentile), head
circumference 29.5 cm (50th percentile). On admission the
overall appearance was consistent with gestational age,
nondysmorphic, anterior fontanel soft, open and flat. Red
reflex deferred. Palate was intact. Respirations were equal
with crackles, diminished bilaterally, with grunting, flaring
and retracting. Heart was regular rate and rhythm without
murmur, 2+ peripheral pulses including femorals. Abdomen was
benign without hepatosplenomegaly or masses; three-vessel
cord. Normal male genitalia with testes descending. Back
normal. Skin slightly mottled and pink. Appropriate tone
and activity level.
HOSPITAL COURSE: 1. Respiratory: The patient was placed on
CPAP of 6 cm of water on admission for grunting, flaring and
retracting; did not require supplemental oxygen. He was
weaned off CPAP to room air on day of life one and has
remained in room air since with comfortable work of
breathing, respiratory rates in the 50s. He has occasional
episodes of apnea and bradycardia, but has not required
caffeine citrate. The last apnea episode was on [**2126-5-22**].
2. Cardiovascular: The patient has been hemodynamically
stable throughout the hospital stay with normal blood
pressure and no heart murmur.
3. Fluids, electrolytes and nutrition: Originally he was
maintained on D10W with maintenance electrolytes added at 24
hours of age. Enterals feeds were started on day of life one
and advanced to full volume feeds on day of life six without
problems. Feeds of premature Enfamil were advanced to 28
calories per ounce with ProMod over several days with
tolerance. At discharge the patient is taking 150 cc per kg
per day divided q. 4 hours with feeds infused over an hour
and a half. Discharge weight was 1,720 grams, length 42.5
cm, head circumference 30 cm.
4. GI: The patient received phototherapy for indirect
hyperbilirubinemia. Peak bilirubin total was 10.4, direct
0.3. Last bilirubin done off phototherapy on [**2125-5-15**] was
total 4.5, direct 0.2.
5. Hematology: Hematocrit on admission was 52.1%. The
patient did not require any blood products during this
admission.
6. Infectious disease: The patient received ampicillin and
gentamicin for 48 hours following delivery for a rule out
sepsis course. Complete blood count on admission showed a
white count of 12.1 with 12 polys, 1 band, 246,000 platelets.
Blood culture was negative.
7. Neurology: A head ultrasound done on day of life eight
was normal. A follow-up head ultrasound is recommended at
one month of age.
8. Sensory: Hearing screening is recommended prior to
discharge. An ophthalmology examination is recommended at
three weeks of age.
CONDITION ON DISCHARGE: Stable 14-day old, now 33-5/7 weeks
corrected age preterm male, growing.
DISPOSITION: The patient is transferred to [**Hospital6 27253**]. His pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 38713**], telephone
number [**Telephone/Fax (1) 38714**].
CARE RECOMMENDATIONS:
1. Feeds: Premature Enfamil 28 calories per ounce with
ProMod 150 cc per kg per day. This is achieved by 24
calories per ounce premature Enfamil with four calories per
ounce of MCT and half a tsp of ProMod per 90 cc of formula.
2. Recommend nutrition laboratory studies in one week to
include calcium, phosphorous, alkaline phosphatase and if
still on ProMod, a BUN and creatinine.
3. Medications: Ferrous sulfate 0.15 cc p.o. daily.
4. Car seat position screening recommended prior to
discharge.
5. State newborn screening done on day of life three and
again at time of transfer.
6. Immunizations received: The patient has not received any
immunizations.
7. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: A. Born at less than 32
weeks. B. Born between 32 and 35 weeks with plans for day
care during RSV season, with a smoker in the household or
with preschool siblings. C. With chronic lung disease.
FOLLOW-UP RECOMMENDED:
1. Ophthalmology examination at three weeks of age.
2. Head ultrasound at one month of age to rule out PVL.
DISCHARGE DIAGNOSES:
1. AGA 31-5/7 weeks preterm male.
2. Twin number two.
3. Respiratory distress likely TTN, resolved.
4. Indirect hyperbilirubinemia, resolved.
5. Apnea of prematurity.
6. Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 36138**]
MEDQUIST36
D: [**2126-5-22**] 13:24
T: [**2126-5-22**] 15:01
JOB#: [**Job Number 48557**]
ICD9 Codes: 7742, V290 | [
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