notes_small.csv

PARSED
"Admission Date:  2174-12-26       Discharge Date:  2175-1-9

Date of Birth:   2174-12-26       Sex:  M

Service:  NEONATOLOGY

HISTORY OF PRESENT ILLNESS:  Baby Candice Kyle Virginia is a
2600 gram boy born at 34-4/7 weeks gestational age to a
34-year-old G2, P0-1 mother.  Prenatal screens were notable
for maternal blood type B positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
Rubella immune, GBS unknown.  No reported pregnancy
complications.  Delivery was done for concerns of ""leaking
fluid.""  No other risk factors.  Delivery by cesarean section
due to breech positioning.  Apgars of 7 at one minute and 9
at five minutes.

The infant was initially sent to the Newborn Nursery for
questions of whether gestational age was actually greater
than 35 weeks.  However, in the Newborn Nursery, poor
regulation of temperature and grunting was noted and the
patient was transferred to the Neonatal Intensive Care Unit
for further management.

PHYSICAL EXAMINATION ON ADMISSION:  Weight 2600 grams (75th
percentile).  General:  Pink, grunting with no retractions or
flaring.  HEENT:  Anterior fontanelle soft and flat, palate
intact.  Clavicles intact.  No ear anomalies.  Neck supple.
Lungs clear to auscultation with good aeration.  Regular rate
and rhythm with no murmur noted, 2+ femoral pulses.  Soft
abdomen with bowel sounds present and no hepatosplenomegaly.
There was bruising of the left flank and inguinal area.
Normal male genitalia with bilaterally descended testes.
Penis patent with no sacral anomalies.  Hips hyperflexed with
knees hyperextended-  typical breech positioning.  Hips stable
with negative Ortolani and Barlow signs.  Extremities pink
and well-perfused.  Tone and activity normal.

HOSPITAL COURSE BY SYSTEM:
1.  Respiratory:  The grunting resolved within the first day
of life and Dr. Geisler has been stable with saturations greater
than 96% with room air without any respiratory distress for
the remainder of the hospitalization.  No active respiratory
issues.  There has been no apnea of prematurity noted.

2.  Cardiovascular:  Dr. Geisler has remained cardiovascularly
stable with an intermittent very soft murmur of no apparant
clinical significance.  On the discharge exam the murmur was
not audible.

3.  Fluids, Electrolytes and Nutrition:  On admission, we
initially attempted ad lib p.o. feeds of Premature Enfamil-20
(mother decided not to breast feed).  However, he was unable
to maintain adequate p.o. intake and was started on p.o. and
p.g. feeds.  By nine days of age his p.o. intake was
improving markedly and he was switched to ad lib p.o.
Enfamil-20 with 140 cc/kg/day minimum.  At the time of
discharge he was taking in ad lib p.o. Enfamil-20 at 166 cc
per kilo per day.  At discharge, his weight was 2595 grams
(still down five grams from birth weight).

4.  Gastrointestinal:  Dr. Geisler was noted to be jaundiced and
phototherapy was started when he was five days old for a
bilirubin of 12.8 total over 0.4 direct.  Phototherapy was
discontinued on 1-2.  He was seven days old with
subsequent bilirubins off phototherapy declining from 5.6
down to 5.3 on 1-5.

5.  Hematology:  Maternal blood type was B positive.  Baby's
blood type is not known.  Hematocrit on admission was 48.  No
transfusions had been required.

6.  Infectious Disease:  Initial sepsis evaluation included a
CBC which showed a white blood cell count of 9.7 with 46%
polys, 1% bands, hematocrit 48, platelets 230.  Blood culture
was negative.  Antibiotics were not initiated given the
absence of significant sepsis risk factors.  He has not had
any active infectious disease issues.

7.  Sensory:  Hearing screening was performed with automated
auditory brainstem responses with pass in both ears.

CONDITION AT DISCHARGE:  Stable.

DISCHARGE DISPOSITION:  Home.

PRIMARY PEDIATRICIAN:  Dr. Karl Stephens, Gonzalez Memorial Hospital.  Phone
number 291-383-8038.

CARE/RECOMMENDATIONS:
1.  Feeds at discharge are Enfamil-20 p.o. ad lib.
2.  No medications.
3.  Car seat position screening passed.
4.  State newborn screen last sent on 12-29 with
results pending.
5.  Hepatitis B immunization #1 administered on 1-2.
6.  Synagis RSV prophylaxis should be considered from December
through November for any of the following three criteria:  A.
Born at less than 32 weeks gestational age; B. Born between
32 and 35 weeks gestational age with two of the following risk
factors: planned daycare, smoker in the house, neuromuscular
disease, airway abnormality or school age siblings; C. with
chronic lung disease.

FOLLOW-UP APPOINTMENTS:  Schedule includes:
1.  An appointment with the primary care physician on
1-10 at 1:30.
2.  Additional follow up should include an ultrasound of the
hips at approximately six weeks of age due to the breech
presentation and according to the latest AAP guidelines.

DISCHARGE DIAGNOSES:
1.  Prematurity at 34-3/7 weeks gestational age.
2.  Mild early respiratory distress consistent with transient
tachypnea of the newborn.
3.  Intermittent soft murmur.
4.  Immature feeding.
5.  Physiologic hyperbilirubinemia.
6.  Sepsis ruled out (off antibiotics).
5.  Breech positioning in utero.




                            Charles Keith, M.D.  D13268118

Dictated By:Bobby
MEDQUIST36

D:  2175-1-9  12:42
T:  2175-1-9  12:46
JOB#:  Job Number 52585
"
"Admission Date:  2133-1-28     Discharge Date:  2133-1-31

Date of Birth:   2063-3-16     Sex:  F

Service:  CCU

CHIEF COMPLAINT:  Chest pain.

HISTORY OF PRESENT ILLNESS:  Ms. Eva is a 69-year-old
woman who was recently discharged from Butler Clinic one week ago with chest pain and
electrocardiogram changes in the inferior leads.

She was then transferred to the cardiac catheterization
laboratory and had a catheterization which revealed she had a
right-dominant system with a 70% proximal lesion and a 95%
mid lesion.  The two lesions were dilated with difficulty.
The ostial lesion was easily stented.  However, the mid
lesion stenting was initially complicated by dissection and
slow flow but was then stented with an additional two stents.
Because the ostial stent had migrated distally, another stent
was placed proximally to reopen the ostial lesion.  She
received a total of five since the RCA approximately one week
ago with dissection mid to distally.

She presents tonight with acute recurrence of her chest pain
with 5-mm to 10-mm ST elevations in the inferior leads, and
was again taken to the catheterization laboratory emergently
this evening.

In the cardiac catheterization laboratory, it was noted that
between two of the mid right coronary artery stents, where
some dissection remained, there was a large fresh thrombus.
Due to technical reasons, this was unable to be stented or
receive Angio-Jet but was amenable to balloon angioplasty.
TIMI-III flow resulted after angioplasty.  There was a stable
70% long tubular lesion of the left anterior descending
artery noted upon the last catheterization.  During the
procedure, the patient experienced transient hypotension to
the 70s and bradycardia which was quickly relieved with
atropine, intravenous fluids, and dopamine.  The dopamine was
turned off at the end of the case, and the patient recovered
with systolic blood pressures in the mid 120s.

She arrived in the Coronary Care Unit without any complaints.

PAST MEDICAL HISTORY:
1.  Prominent coronary artery disease, status post
catheterization 17 years ago which was reported as negative;
and as above in the History of Present Illness.
2.  Hypertension.
3.  Hypercholesterolemia.

MEDICATIONS ON ADMISSION:  Aspirin 325 mg p.o. q.d.,
Plavix 75 mg p.o. q.d. times 90 days, Lovenox 30 mg
subcutaneous b.i.d., atenolol 25 mg p.o. q.d., Lipitor 80 mg
p.o. q.d., Prinzide 20/12.5 1 tablet p.o. q.d.

ALLERGIES:  CODEINE and BENADRYL.

SOCIAL HISTORY:  Denies any tobacco.  Admits to drinking
alcohol socially.

PHYSICAL EXAMINATION ON PRESENTATION:  On physical
examination her pulse was 80, blood pressure of 124/52,
respiratory rate of 16, satting 100% on 2 liters.  In
general, she was comfortable, in no apparent distress, lying
flat.  Head, eyes, ears, nose, and throat revealed pupils
were equally round and reactive to light.  Sclerae were
anicteric.  The oropharynx was clear.  Neck revealed jugular
venous pulsation was approximately 4 cm at 10 degrees.
Respiratory was clear to auscultation bilaterally.
Cardiovascular revealed a regular rate and rhythm.  No
murmurs, rubs or gallops.  Abdominal examination was benign.
Extremities revealed no cyanosis, clubbing or edema.  She had
good distal pulses.

RADIOLOGY/IMAGING:  Her electrocardiogram revealed that she
was in normal sinus rhythm at a rate of 84.  She had 5-mm to
10-mm ST elevations in leads II, III, and aVF; with
reciprocal ST depressions in V1, V2, and V3.

Post catheterization electrocardiogram revealed that she was
in normal sinus rhythm with left axis deviation, Q waves
inferiorly, with resolving ST-T wave changes.

HOSPITAL COURSE:  Her hematocrit was found to be 26.9 post
catheterization and she was transfused 2 units of packed red
blood cells which increased her hematocrit to 35.7.  She was
then transferred to the floor for further observation.

A transthoracic echocardiogram revealed that her left atrium
was moderately dilated.   There was mild symmetric left
ventricular hypertrophy with a normal left ventricular cavity
size.  There was mild regional left ventricular systolic
dysfunction with hypokinesis/akinesis of the inferior septum
and inferoposterior wall.  She ejection fraction was noted to
be 40% to 45%.  Her right ventricular size and systolic
function were normal.  She had 1+ mild aortic regurgitation
and moderate 2+ mitral regurgitation.

Examination of her groin revealed no hematoma.  Her femoral
and distal pulses were 2+.  Because a left femoral bruit was
heard on auscultation, a femoral ultrasound was obtained
which revealed no evidence of left inguinal pseudoaneurysm or
arteriovenous fistula.  Her creatine kinases steadily trended
downward, and her creatinine remained stable status post
catheterization.

CONDITION AT DISCHARGE:  Condition on discharge at the time
of discharge was stable.

DISCHARGE STATUS:  Discharged to home.

MEDICATIONS ON DISCHARGE:
1.  Prinzide 20/12.5 1 tablet p.o. q.d.
2.  Atenolol 25 mg p.o. q.d.
3.  Lovenox 60 mg subcutaneous b.i.d. times two weeks.
4.  Lipitor 80 mg p.o. q.d.
5.  Plavix 75 mg p.o. q.d. times six months.
6.  Aspirin 325 mg p.o. q.d.
7.  Sublingual nitroglycerin 0.4 mg sublingually q.5min.
times three p.r.n. for chest pain.

DISCHARGE INSTRUCTIONS:  Return to the hospital if you
develop worsening chest pain or shortness of breath, or if
you develop worsening back pain, leg pain, or flank pain.

DISCHARGE FOLLOWUP:   Follow up with your cardiologist
Dr. Woolery at Sanders Medical Center Hospital in one week.

DISCHARGE DIAGNOSES:
1.  Coronary artery disease.
2.  Hypertension.
3.  Hypercholesterolemia.




                          Walter Gutierrez, M.D.  T37912963

Dictated By:Hancock

MEDQUIST36

D:  2133-2-3  14:59
T:  2133-2-3  18:51
JOB#:  Job Number 104258

cc:Sorrell Memorial Hospital"
"Admission Date:  2181-4-25              Discharge Date:   2181-5-4


Service: MEDICINE

Allergies:
Amiodarone / Quinidine/Quinine

Attending:Gregory
Chief Complaint:
CC:CC Contact Info 94136
Major Surgical or Invasive Procedure:
hemodialysis


History of Present Illness:
HPI: This is a 88My.o male with h/o of afib on comadin, CHF,
OSA, and advance prostate CA s/p TURP, h/o urosepsis sp b/l
stents, seen in clinic c/foul smelling urine today.
.
Patient describes that over the last 2 days he has been feeeling
more tired, lack of energy and his urine is coming out ""milky
and foul smelling"". He was given two doses of TMP/SMX or ?Cipro
last night and one this morning.
.
He denies any fever, chills, nausea, vomit, diaphroesis,
shortness of breath, chest pain, back pain, diarrhea, aabdominal
pain, but reported 10 lb wt loss in the past 3 months due to
loss of appetite from lost of taste budd.
When asked about his bruise on his left forehead, he said that
he bumped his head on Sunday with the refrigerator. He did not
lose any conciousness. Denies any headachees, blurred vision or
unsteady gait associated after the episode.
.
In ED, hemodynamically stable, has +UA, received Levoflox, and
cefepime.

Past Medical History:
PMH -
- OSA
- History of sinus infections.
- Prostate CA s/p XRT/resection
- DM2
- A. fib on Coumadin
- Right cataract.
- Left retinal tear.
- Macular degeneration status post laser treatment.
- Gout.
- Clarence Mcdonald tear.
- Squamous cell carcinoma of ear followed by derm
- IBS w/chronic diarrhea for years/lactulose intolerance
- myelodysplasia
.
PSH -
- Spontaneous pneumothorax 15 years ago.
- s/p cholecystectomy
- s/p left inguinal hernia repair,
- s/p hemorrhoidectomy
- Prostate CA s/p TURP and XRT s/p urethral stricture
- back surgery


Social History:
SH - Retired psychiatrist. Lives at home with his wife. Quit
tobacco many years ago. No EtOH, no illicits.


Family History:
FH - NC

Physical Exam:
Physical Exam:
Vitals: T 96.9 P: 67 BP 146/66 RR 17 Sats 96%RA
General: Awake, alert, NAD.
HEENT: dry oral mucose. echimosis on his left forehead.
Neck: supple, no JVD, left side adenopathy x 2, small, non
tender, mobile.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: BS+, soft, obese non tender, mildly distended. Liver
1cm below costal margin.
Extremities: asymetric bilateral LLE edema 2+.
Neurologic:
-mental status: Alert, oriented x 3. CNII-XII intact. Movilizing
all extremities.

Pertinent Results:
Laboratory Data: see below
EKG: afib, with VR 70x, left axis, no st changes, difuse
flattenin t waves on v4-v5-v6. QTC 460
.
Radiologic Data:
Renal US: pending
.

2181-4-25 05:40PM BLOOD WBC-12.1* RBC-4.64 Hgb-12.5* Hct-40.4
MCV-87 MCH-26.9* MCHC-30.8* RDW-17.3* Plt Ct-258
2181-5-4 04:21AM BLOOD WBC-19.7* RBC-3.46* Hgb-9.9* Hct-29.9*
MCV-87 MCH-28.6 MCHC-33.0 RDW-18.5* Plt Ct-93*
2181-4-25 05:40PM BLOOD PT-74.7* PTT-42.8* INR(PT)-9.7*
2181-4-25 05:40PM BLOOD Plt Smr-NORMAL Plt Ct-258
2181-5-4 04:21AM BLOOD PT-23.7* PTT-29.7 INR(PT)-2.4*
2181-5-4 04:21AM BLOOD Plt Smr-LOW Plt Ct-93*
2181-4-25 05:40PM BLOOD Glucose-304* UreaN-59* Creat-2.4* Na-136
K-4.2 Cl-101 HCO3-20* AnGap-19
2181-5-3 05:41AM BLOOD Glucose-89 UreaN-63* Creat-3.7* Na-125*
K-6.6* Cl-94* HCO3-10* AnGap-28*
2181-5-4 04:21AM BLOOD Glucose-116* UreaN-60* Creat-3.6* Na-130*
K-5.2* Cl-91* HCO3-13* AnGap-31*
2181-4-27 06:45AM BLOOD ALT-32 AST-57* LD(LDH)-529* AlkPhos-312*
TotBili-1.0
2181-5-4 04:21AM BLOOD ALT-476* AST-PND LD(LDH)-PND AlkPhos-573*
TotBili-1.9*
2181-5-4 04:21AM BLOOD Albumin-2.2* Calcium-7.2* Phos-8.5*
Mg-2.0
2181-4-27 06:45AM BLOOD PSA-<0.1
2181-5-3 12:51PM BLOOD Type-ART pO2-81* pCO2-25* pH-7.04*
calHCO3-7* Base XS--23
2181-5-3 07:11PM BLOOD Type-Smith Temp-35.0 O2 Flow-3 pO2-37*
pCO2-28* pH-7.20* calHCO3-11* Base XS--16 Intubat-NOT INTUBA

Brief Hospital Course:
87 y/o male with advanced prostate CA s/p TURP, h/o bilateral
hydronephrosis due to tumor at trigone s/p post stents (Right),
OSA, afib on coumadin who presents with UTI and ARF on CRI, and
elevated INR.  Given worsening renal failure secondary to
underlying metatstaic malingnancy and poor prognosis, Cory wife
and family decided to concentrate on comfort and avoid
aggressive measures.  After several sessions of hemodialysis,
Family chose to further withdrawl care. Pt pronounced dead at
15:36 on 2181-5-4. Family present in the room. Autopsy deferred
.
#. Acute on chronic renal failure - Patient has a baseline Cr of
1.6 with an elevation in BUN/Cr to 59/2.4. Pt with progressive
renal failure 1-18 to underlying malignancy and associated
obstruction.  Pt initiated on Hemodialysis which he tolerated
well.  Discussed with urology who recomended revision of uretral
stents which was not pursued as family wished to stress comfort.

.
# UTI: u/a compatible with urinary tract infection. Given prior
history of VRE and gram negative bacteremia (pseudomona) in
recent past, Pt was covered broadly.
.
#. Anion Gap Acidosis: Mixed lactic acidosis with acute renal
failure.  BG elevated on presentation, but urine ketones
negative.  Pt started on NaHCO3 and HD with little improvement
in acidosis.  Worsening lactic acidosis 1-18 tumor necrosis


Medications on Admission:
.
Medications:
Lasix 60 mg a day, Glipizide ER 10 mg, Lipitor 10 mg, Casodex 50

mg, Allopurinol 100 mg, potassium 10 mEq, Verapamil 40 mg,
Prilosec OTC 20 mg, vitamin B-12, Coumadin, 1-2.5 mg as dosed by

his INR, folic acid 1 mg a day, cholestyramine 1 pack daily,
ferrous sulfate, nitrofurantoin which he just finished as I
mentioned, and Ambien XL 6.25 mg.

Discharge Medications:
na

Discharge Disposition:
Home with Service

Discharge Diagnosis:
renal failure
hyperkalemia


Discharge Condition:
deceased


Discharge Instructions:
none

Followup Instructions:
NA



"
"Admission Date:  2182-7-23       Discharge Date: 2182-7-29


Service:

This is an 84-year-old female who was initially evaluated for
progressive claudication and rest pain.  She was hospitalized
2182-7-11 to 2182-7-12 during this admission she was evaluated by
Cardiology because of her known extensive coronary artery
disease.  She underwent a P-Thal at that time which showed no
angina symptoms or ischemic electrocardiogram changes though
the nuclear report was negative for a reversal ischemic
effect however, due to the patient's high risk Cardiology
recommended a cardiac catheterization for further evaluation.
The patient refused cardiac catheterization and chose to be
discharged to home to take care of ""personal matters""before
undergoing any vascular surgery.

The patient returns now for elective surgery.

PAST MEDICAL HISTORY:  No known drug allergies.

ADMISSION MEDICATIONS:
1.  Colace 100 mg at h.s.
2.  Milk of Magnesia 30 cc's p.o. p.r.n.
3.  Dulcolax suppository p.r.n.
4.  Vicodin tablets, one q 4 hours p.r.n.
5.  Nitroglycerin sublingual 0.4 mg p.r.n.
6.  Glucotrol 10 mg b.i.d.
7.  Lopressor 12.5 mg p.o. b.i.d.
8.  Flagyl 500 mg three times a day.
9.  Aspirin 325 mg p.o. daily.
10. Levaquin 500 mg q day.
11. Vitamin D complex 100 mg q day.
12. Vitamin C 500 mg q day.
13. Vitamin E 400 units q day.
14. Lasix 20 mg q day.
15. Oxycontin 20 mg q 12 hours.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post myocardial
infarction in 2182-3-25, status post cardiac catheterization
with Triple vessel disease.
2.  Diabetes mellitus Type II.
3.  Hypertension.
4.  Osteoarthritis.
5.  Radiculopathy.
6.  Psoriasis.

PAST SURGICAL HISTORY: Status post hysterectomy and bilateral
oophorectomy in 2160.  Status post cholecystectomy.  Status
post Cesarean section times four.  Status post bilateral
cataract surgery.

PHYSICAL EXAMINATION:  General appearance, alert and
cooperative female in no acute distress.  Vital signs:  98.5,
98, 62, blood pressure 110/60.  Respiratory rate 18, O2 sat
95% on room air.

Head, eyes, ears, nose and throat examination:  Pupils are
small, minimally reactive, equal bilateral.  Cardiac exam is
regular rate and rhythm with no murmurs.  Respiratory:  Clear
the auscultation bilateral.  Abdominal exam is unremarkable.
Extremities show right great toe gangrene, some erythema on
the right foot.  Pulse exam shows Dopplerable posterior
tibial pulse.  Left leg there is no dorsalis pedis pulse on
the right or the left and there is no posterior tibial pulse
on the right.  The femoral pulses are dopplerable
bilaterally.

HOSPITAL COURSE:  The patient was brought to the preoperative
holding area.  She underwent on 2182-7-23 a right iliofemoral
bypass graft with 8 mm Dacron and a right first toe
amputation.  Her intraoperative course was complicated by
massive bleed requiring 11 units of packed red blood cells of
FFP and 750 cc's of crystalloid.  The patient was admitted to
the SICU postoperatively for continued care.  Her postop CBC
was white count 10.1, hematocrit 45.5, platelet count 48 K.
BUN 20, creatinine 1.1, K 4.1.  Blood gases:  7.30, 39, 180,
18, -7.  The Troponin was less than .3.

Chest x-ray was without pneumothorax, Swann-Ganz was in good
position.  Exam showed arm Dopplerable biphasic pulses,
popliteal, no Dorsalis pedis or posterior tibial.  The
patient remained in the Intensive Care Unit postoperative day
one.  Overnight events is low urinary output requiring volume
supplementation.  White count 15.8, hematocrit 40.5 with a
platelet count of 55.  BUN and creatinine remained stable.
Coags were normal.  The right foot was warm with Dopplerable
biphasic posterior tibial but no dorsalis pedis, she had a
palpable femoral and the wounds were clean, dry and intact.

The patient remained in the SICU, intubated until her
acidosis was corrected.  She remained on Levofloxacin and
Flagyl perioperatively while lines were in place.
Postoperative day two there were no overnight events.  She
remained hemodynamically stable.  Her white count was 16.6,
hematocrit 38.3.  BUN and creatinine remained stable.  K of
3.9 which was supplemented.  She was weaned and extubated.
She required Lasix for diuresis.

Postop day three, the patient was transferred to the MICU for
continued monitor and care.  Postoperative day four there
were no overnight events.  She continued to do well, her
hematocrit was 36.9, BUN 26, creatinine 1.0, K 3.6.  She was
tolerating orals well, her fluids were Hep-locked.  Her
Levofloxacin and Flagyl were discontinued and Kefzol was
begun.  The patient was transferred to the regular nursing
floor.  Physical therapy was consulted for assessment for
discharge planning.

Postoperative day two she continued to do well, she remained
afebrile, hemodynamically stable, incisions were clean, dry
and intact.  Her amputation site was clean, dry and intact.
She had a dopplerable pulses bilaterally.  Case management
began screening.  The patient was transferred to
rehabilitation for continuing monitoring and care.  Condition
was stable.  At the time of discharge her hematocrit was
36.2.

DISCHARGE MEDICATIONS:
1.  Lasix 40 mg q day.
2.  Acetaminophen 325 mg to 650 mg q day.
3.  Heparin 5000 units subcutaneously q 12 hours.
4.  Aspirin 325 mg q day.
5.  Insulin sliding scale, please see flow sheet.
6.  Albuterol and Ipratropium inhalers one to two puffs
    q 4 hours p.r.n.
7.  Metoprolol 12.5 mg b.i.d. hold for systolic blood
    pressure of less than 100, heart rate less than 60.
8.  Percocet tablets 5/325 mg one to two q 4 to 6 hours
    p.r.n. for pain.

DISCHARGE DIAGNOSIS:
1.  Right iliac occlusion with first right toe gangrene.
    Status post right ileofem bypass with 8 mm Dacron and
    a right first toe amputation.
2.  Blood loss anemia, corrected.
3.  Thrombocytopenia secondary to multiple transfusions,
    stabilized.
4.  Coronary artery disease stable.
5.  Type 2 diabetes mellitus stable.
6.  Hypertension controlled.
7.  Osteoarthritis stable.






                            Charles Wells, M.D.  N52931579

Dictated By:Ellis
MEDQUIST36

D:  2182-7-29  13:44
T:  2182-7-29  16:12
JOB#:  Job Number 
"
"Unit No:  70286
Admission Date: 2155-5-2
Discharge Date: 2155-5-11
Date of Birth:  2097-3-27
Sex:  M
Service:  ENT


PRIMARY DIAGNOSIS:  Invasive thyroid cancer.

PRIMARY PROCEDURE:  Total thyroidectomy, central neck
dissection, resection of cricothyroid membrane.

HISTORY OF PRESENT ILLNESS:  Mr. Lloyd Tory is a 58-year-
old gentleman with a large anterior neck mass, known to be a
thyroid cancer. This mass is invasive into his cricothyroid
membrane. He presents for surgical correction.

PAST MEDICAL HISTORY:
1. Urinary stricture.
2. Type 2 diabetes.


MEDICATIONS:  None

ALLERGIES:  No known drug allergies.

COURSE IN HOSPITAL:  Mr. Tory was taken to the operating
room on 2155-5-2. He underwent a total thyroidectomy with
central lymph node dissection, as well as cricotracheal
resection. The start of the case was delayed as the nurses
and residents were unable to place a Foley catheter.
Intraoperative urology consultation was obtained. The patient
underwent a rigid cystoscopy in order to place a Foley
catheter. Dense strictures throughout his urethra were found.

Postoperatively, Mr. Tory was observed in the PAC unit for
two nights. He was kept intubated until postoperative day #3.
No NG tube was placed for fear of damaging the area of the
cricotracheal resection and reconstruction.

On postoperative day #1 Mr. Tory was noted to have some
runs of supraventricular tachycardia. An EKG was done and was
normal. His electrolytes were managed and this spontaneously
resolved.

On postoperative day #2 Mr. Horace calcium was noted to
trend down. He was started on calcium intravenously, as he
was still intubated.

On postoperative day #3 Mr. Tory was weaned off the
ventilator, however, after extubation he became stridorous
with increasing work of breathing. He required reintubation.
For this reason he underwent a tracheostomy on the same day.

Hematology oncology consultation was requested given the
invasive nature of the patient's thyroid carcinoma.

On postoperative day #4 Mr. Tory was successfully weaned
off the vent and onto a tracheostomy collar. As his calcium
started to drop further, he was started on calcium twice a
day, as well as Rocaltrol 0.5 mcg daily.

On postoperative day #5 the patient's cuff was taken down and
he was started on calcium, as well as Rocaltrol for dropping
calcium.

He was seen by the speech and swallow team. The patient was
noted to have gross aspiration on his first few days of
swallow on 2155-5-7. However, the speech and swallow team
had a Passy-Muir valve placed for the patient, which he did
well with while awake and not eating.

The patient was given a Passy-Muir valve by the speech and
swallow team, which he did well with when he was awake.

On postoperative day #6 the patient was started on p.o. He
could also be started on p.o. medication including
liothyroxine 50 mcg p.o. daily and his calcium was increased
to 2 gm twice a day. His Rocaltrol was also increased to 0.5
mcg p.o. daily.

On postoperative day #6 urology was reconsulted to see if
there was any further recommendations to be made about his
Foley catheter. They recommended discontinuing his Foley and
catheterizing himself once per day. The patient received
adequate teaching in hospital and was prepared to do this
task by the time he went home.

On 5-8, the endocrine service was consulted because of Mr.
Horace hypocalcemia. They recommended increasing his
calcium carbonate to 500 mg p.o. four times daily and
continue his Calcitrol at 0.5 mcg daily. They also
recommended changing the parathyroid hormone level.

On postoperative day #7, Mr. Tory did have his Foley
removed and was  taught to straight catheterize. His blood
sugars came under better control as he was started on
metformin.

A radiation oncology consultation was obtained to see if
radiation would be of benefit for Mr. Tory, given the
aggressiveness of his cancer.

On 2155-5-9, Mr. Tory was seen by speech and swallow
again. His speech and swallow examination revealed minimal
penetration with liquids and trace aspiration. They
recommended him receiving an oral diet, which he did
successfully. He was able to have his nasogastric tube
removed and was discharged home in stable condition on 2155-5-10.

CONDITION ON DISCHARGE:  Afebrile. Vital signs stable.
Patient was tolerating a full soft solid diet. His neck was
flat. His incision was clean, dry and intact. The
tracheostomy site was clean. Cranial nerves V-VII and Dr. Zbinden-XII
were intact.

INSTRUCTIONS ON DISCHARGE:  Mr. Tory is to followup with
Dr. Wheeler. He was instructed to call and make an
appointment. He is to call Dr.Erin office or
proceed to the closest emergency room if he experiences
fever, wound redness or drainage or any other significant
problems. Mr. Tory is to straight catheterize himself once
per day in order to keep his urethra patent. He is to
followup with a urologist, which will be coordinated by his
primary care physician. Mandi is also to followup with Dr.
Drake, of radiation oncology. The patient also has his
own private endocrinologist, whom he is to followup with.

MEDICATIONS ON DISCHARGE:
1. Levoxyl 100 mcg p.o. daily
2. Calcitrol 0.25 mcg p.o. twice a day
3. Percocet 1-2 tablets p.o. q.4-6h p.r.n. for pain.
4. Famotidine 20 mg p.o. twice a day.
5.
   Metformin 500 mg p.o. q.a.m.
6. Calcium carbonate 1250 mg p.o. twice a day.




                        Christopher Martinez, V48469443

Dictated By:Lamb
MEDQUIST36
D:  2155-6-3 10:14:44
T:  2155-6-3 15:05:13
Job#:  Job Number 33224





"
"Admission Date:  2183-12-31       Discharge Date:  2184-1-11


Service:

ADMISSION DIAGNOSIS:
Right colon cancer.

HISTORY OF PRESENT ILLNESS:  The patient is a 76-year-old
woman with a history of diabetes mellitus, hypertension and
elevated cholesterol who, on an evaluation as an outpatient,
was found to be anemic and a colonoscopy revealed a right
colon cancer in 2183-12-18.  The patient was then
scheduled for elective right colectomy.

PAST MEDICAL HISTORY:  As above.

MEDICATIONS ON ADMISSION:
Procardia 60 mg p.o. q.d.
Captopril 50 mg p.o. t.i.d.
Lipitor 10 mg p.o. q.d.
Insulin 409 units of NPH q.a.m.

PAST SURGICAL HISTORY:  The patient had an open
cholecystectomy in 2162.

ALLERGIES:  The patient had an allergy to penicillin.

PHYSICAL EXAMINATION:  Vital signs revealed a temperature of
98.8??????F, a heart rate of 100, a blood pressure of 136/59,
respirations of 18 and an oxygen saturation of 100% on room
air.  In general, the patient was a pleasant, obese, elderly
woman.  On head, eyes, ears, nose and throat examination, the
mucous membranes were moist.  The neck had no
lymphadenopathy.  The heart had a regular rate and rhythm.
The lungs were clear.  The abdomen was soft.  There was mild
right sided tenderness and the abdomen was nondistended.

LABORATORY:  The patient had a white blood cell count of
13,100 with a hematocrit of 35.5 and a platelet count of
543,000.  Potassium was 4.0.  BUN was 12 and creatinine was
0.7.  Glucose was 130.

RADIOLOGY:  A chest x-ray showed no evidence of infiltrate or
metastatic disease.

ELECTROCARDIOGRAM:  An electrocardiogram had sinus rhythm at
100.

HOSPITAL COURSE:  The patient was admitted for bowel prep and
tolerated the bowel prep.  On 2184-1-2, she underwent right
colectomy without complications.  Postoperatively on that
night, the patient was stable.  However, she required
intravenous fluid bolus for low urine output.

On postoperative day #1, the patient continued to require
intravenous fluid boluses for urine output and developed a
persistent tachycardia.  After receiving intravenous fluid
resuscitating without good response to intravenous fluid
bolus, the patient became short of breath and was transferred
to the Intensive Care Unit for further management.

The patient was treated for congestive heart failure and was
ruled in for a myocardial infarction with electrocardiogram
changes and elevated levels of troponin.  A cardiology
consultation was requested and an echocardiogram was
performed, which revealed a significantly decreased ejection
fraction of approximately 15% with severe hypokinesis and
akinesis of the inferior and lateral walls.  The patient was
started on beta blocker and ACE inhibitor for afterload
reduction to optimize her hemodynamics.  The patient was also
started on aspirin.

Once her hemodynamics were optimized and diuresis of fluid
was initiated, the patient improved and, on postoperative day
#4, she was transferred back to the hospital floor.  The
patient then soon passed flatus and was slowly advanced to a
regular diet.  She was continued on Lasix diuresis as well as
beta blockade, afterload reduction and aspirin.

The patient continued to do well with good response to
diuresis and improved pulmonary function and was saturating
well on room air and breathing comfortably.  On postoperative
day #9, the patient was tolerating a regular diet and was
ambulatory with physical therapy.  However, the patient
required significant assistance, which indicated a
rehabilitation transfer.

On postoperative day #7, an ultrasound of the right upper
extremity was performed, which showed a cephalic vein deep
vein thrombosis, and the patient was started on Coumadin at
that time for treatment of the deep vein thrombosis as well
as for prophylaxis for the severe wall motion abnormality of
the heart.

DISCHARGE DIAGNOSIS:
1.  Right colon cancer.
2.  Status post right colectomy on 2184-1-2.
3.  Postoperative myocardial infarction.
4.  Diabetes mellitus.
5.  Hypertension.
6.  Elevated cholesterol.
7.  Right cephalic vein deep vein thrombosis.

DISCHARGE MEDICATIONS:
1.  Lopressor 25 mg p.o. b.i.d.
2.  Captopril 50 mg p.o. t.i.d.
3.  Coumadin, adjust for INR of 2 to 3.
4.  Lasix 40 mg p.o. b.i.d.
5.  Daniel Finlay 20 mEq p.o. b.i.d.
6.  Percocet one to two tablets p.o. every three to four
hours p.r.n. for pain.
7.  Aspirin.
8.  Clonidine patch.
9.  Subcutaneous heparin.
10. Insulin sliding scale.




                            Richard Lavender, M.D.  H33349570

Dictated By:Jordan
MEDQUIST36

D:  2184-1-10  22:06
T:  2184-1-10  22:56
JOB#:  Job Number 104767
"
"Name:  William, Joshua                    Unit No:  82021

Admission Date:  2125-7-3     Discharge Date:  2125-7-8

Date of Birth:   2044-5-5     Sex:  M

Service:

ADDENDUM:

CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):

4.  CORONARY ARTERY DISEASE ISSUES:  The patient was switched
from his home atenolol to metoprolol while in house.  His
Isordil was held, and he was continued on his home dose of
Pravachol.

His cardiac enzymes were cycled on admission and remained
negative.  A repeat cycling of enzymes was done following an
episode of pulmonary edema.  His troponin T peaked at 0.1,
but creatine kinase and CK/MB levels remained negative.

The patient was ultimately discharged on metoprolol 50 mg by
mouth twice per day in addition to lisinopril 10 mg by mouth
once per day.

5.  STATUS POST FEMORAL-POPLITEAL BYPASS ISSUES:  For this
history, the patient received perioperative ampicillin prior
to undergoing esophagogastroduodenoscopy.

6.  ATRIAL FIBRILLATION ISSUES:  The patient's
anticoagulation was reversed with fresh frozen plasma and
vitamin K.  Plan for continuation off of anticoagulation for
the several weeks considering the severity of his
gastrointestinal bleed.

CONDITION AT DISCHARGE:  Ambulating independently.  His
hematocrit remained stable overnight with a discharge
hematocrit of 36.8.

DISCHARGE STATUS:  The patient was discharged to home.

DISCHARGE DIAGNOSES:
1.  Gastrointestinal bleed.
2.  Atrial fibrillation.
3.  Anemia secondary to blood loss.
4.  Congestive heart failure.
5.  Coagulopathy secondary to anticoagulation with Coumadin.

MEDICATIONS ON DISCHARGE:
1.  Pravastatin 40 mg by mouth at hour of sleep.
2.  Timolol 0.25% drops one drop each eye twice per day.
3.  Metoprolol 50 mg by mouth twice per day.
4.  Protonix 40 mg by mouth once per day.
5.  Lisinopril 10 mg by mouth once per day.

DISCHARGE INSTRUCTIONS/FOLLOWUP:
1.  The patient was instructed to contact his primary care
physician to schedule followup within one to two weeks.
2.  The patient was informed that it was imperative to follow
up with his primary care physician to Charles his
anticoagulation.




                          Joseph Nelson, M.D.
I38071681

Dictated By:Elmer

MEDQUIST36

D:  2125-10-3  17:05
T:  2125-10-4  07:13
JOB#:  Job Number 18338
"
"Unit No:  19413
Admission Date: 2197-8-9
Discharge Date: 2197-8-9
Date of Birth:  2197-8-9
Sex:  F
Service:  NB


HISTORY:  Baby Girl Judy is the 2.025 kg infant born via C-
section for failure to progress at 34-3/7 weeks gestation
with an estimated date of confinement of 2197-9-17.
She was born to a 30-year-old gravida 1, para 0 mother with
prenatal screens blood type B negative, antibody negative,
RPR nonreactive, rubella immune, hepatitis B negative and GBS
unknown. Pregnancy was complicated by a late diagnosis on
fetal ultrasound of polyhydramnios and duodenal atresia. The
mom was seen and brought to the hospital. She was noted to
have fetal anomaly. She was transferred to Anderson Memorial Hospital for further management. The mom
reported that she had been leaking amniotic fluid for the
past 2 weeks, but prior to deliver, she was noted to have a
bulging bag which was ruptured at 10 p.m. the night before
delivery. The infant was born again by cesarean section for
failure to progress with Apgar scores of 7 and 8. In the
delivery room, there was late clampage of the cord with a
minimal amount of blood loss. The infant was transferred to
the NICU for further management.

FAMILY HISTORY:  Mom has history of HSV with her last
outbreak 9 years ago. The family has a 9-year-old niece who
has trisomy 21.

SOCIAL HISTORY:  The parents are married. The mother denied
any tobacco, alcohol or drugs.

PHYSICAL EXAMINATION ON ADMISSION:  The infant was in bed in
no apparent distress. Some facies typical of Down syndrome or
trisomy 21. Her temperature was 98.5, heart rate 175,
respiratory rate 46, blood pressure 63/49 with a mean of 54,
oxygen saturation 100% on room air. Her D-stick was 66. Her
weight was 2215 gm which is the 50th percentile. The head
circumference was 31.5 cm which is 25th-50th percentile, and
her length was 47 cm which is the 90th percentile. HEENT:
There was molding of the head with a moderate caput noted on
the left temporoparietal region. Her anterior fontanelle was
open and flat. Her palate was intact. She had flat facies
with slanted palpebra fissures. Her red reflux was present
bilaterally. No Brushfield spots were noted. Her tongue was
protruding, and her ears were small. Her neck was supple. Her
skin was pink, clear. Her lungs were clear to auscultation
bilaterally. CV had regular rate and rhythm with no murmur.
Femoral pulses were 2+ bilaterally. GU: She had immature
female external genitalia. Her anus was patent. Her spine was
midline. Her clavicles were intact. Her extremities were warm
and well perfused with brisk capillary refill. She had mild
clinodactyly noted on bilateral fifth digits, left greater
than right. She had normal palmar creases. She had sandal
toes present. Neurologically, she had globally decreased
tone, but she had a normal suck.

HOSPITAL COURSE:  Respiratory: She was on room air and
remained comfortable throughout the hospitalization.

Cardiovascular: She was stable without issues. She should
likely have an echocardiogram for evaluation.

Fluids, electrolytes and nutrition: Her D-stick was stable.
She was made n.p.o. She was maintained on IV fluid of D10 at
60 mL/kg per day.

GI: She was noted to have duodenal atresia confirmed by x-
ray. Surgery was consulted.

Hematology: She had a hematocrit of 41 and plt count 231 prior to
discharge.

Infectious disease: There is a potential history of prolonged
rupture of membranes. She had a CBC that showed wbc count 12.2
(69P 0B 27L).  Blood cultures were sent prior to discharge. She
did not start on antibiotics.

Neurology: She seemed neurologically intact at the time.

Genetics: She had a karyotype and a FISH for trisomy 21 sent
prior to discharge.

Sensory: Hearing screen was not performed. We recommend one
prior to her discharge to home.


CONDITION ON DISCHARGE:  Stable.

DISCHARGE DISPOSITION:  To Vasquez Hospital NICU.

PRIMARY CARE PEDIATRICIAN:  The parents cannot recall at this
time, but they said that physician is in Lynda.

CARE AND RECOMMENDATIONS:
1.  Feeds at time of discharge: N.p.o. on IV fluids.
2.  Medications: None.
3.  Car seat positioning should probably be done prior to
    discharge.
4.  State newborn screen: One was drawn prior to discharge but
    because the infant was less than 24 hours old and not yet
    feeding, a repeat will need to be done.
5.  Immunizations received: None.
6.  Immunization recommendations: RSV prophylaxis should be
    considered from March through December for infants who
    meet any of the following 4 criteria - (a) born at less
    than 32 weeks; (b) born between 32 and 35 weeks with 2 of
    the following - daycare during RSV season, a smoker in
    the household, neuromuscular disease, airway
    abnormalities, school age siblings; (c) chronic lung
    disease; (d) hemodynamically significant chronic lung
    disease.
7.  Influenza immunization is recommended annually in the
    fall for all infants once they reach 6 months of age.
    Before this age and for the first 6 months of the child's
    life, immunization against influenza is recommended for
    household contacts and out of home caregivers.
8.  This infant has not received Rotavirus vaccine. The
    American Academy of Pediatrics recommends initial
    vaccination of preterm infants at or following discharge
    from the hospital if they are clinically stable and at
    least 6 weeks but fewer than 12 weeks of age.

DISCHARGE DIAGNOSES:
1.  Prematurity at 34-3/7 weeks.
2.  Possible trisomy 21.
3.  Possible sepsis.
4.  Duodenal atresia.



                        Robert Pamela, MD N25676134

Dictated By:Tobin
MEDQUIST36
D:  2197-8-9 14:49:15
T:  2197-8-9 15:19:36
Job#:  Job Number 74014
"
"Admission Date:  2118-4-26       Discharge Date:  2118-5-6

Date of Birth:   2068-7-18       Sex:  F

Service:  #58

HISTORY OF PRESENT ILLNESS:  The patient is a 49 year-old
woman diagnosed with metastatic renal cell cancer with spinal
and pelvic mets on 2118-3-27.  The patient had a bony
destruction of the left pedicle of L3 as well as posterior
elements on the left side of L3 with impingement on the L3
nerve root without evidence of cord compression.  The patient
is preoped for lumbar embolization, renal embolization
followed by left radical nephrectomy and removal of the L3
vertebra and L2-L4 spinal fusion.

PAST MEDICAL HISTORY:  None.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:
1.  Oxycontin SR.
2.  Percocet.
3.  Colace.
4.  Ambien.

PHYSICAL EXAMINATION:  In general, the patient was awake,
alert and oriented times three, pleasant, cachectic looking
female.  Temperature 100.  Blood pressure 120/62.  Heart rate
117.  Respiratory rate 18.  Sat 98%.  Pupils are equal, round
and reactive to light.  Mucous membranes are moist. Neck was
supple.  Pulmonary clear bilaterally.  Cardiac tachy S1 and
S2 within normal limits.  Abdomen soft, nontender,
nondistended.  Positive bowel sounds.  Extremities no edema.
Back there was no swelling in the lumbar area.
Neurologically the patient was awake, alert and oriented
times three.  Cranial nerves II through XII were intact,
mildly symmetric.  She had no drift.  Her strength was 5 out
of 5 in all muscle groups.  Her sensation was intact to light
touch.  She was hyperreflexic throughout with clonus of the
left lower extremity.

PREOPERATIVE LABORATORIES:  Sodium was 137, K 4.9, chloride
99, CO2 29, BUN 15, creatinine .8, glucose 154.

HOSPITAL COURSE:  The patient was preoped for a embolization
of her lumbar spine area, which was done on 2118-4-28 without
complications.  The patient was monitored in the Intensive
Care Unit postoperatively.  The patient then underwent an
embolization of her right kidney on 2118-4-28 without
complications.  She was again monitored in the Intensive Care
Unit and then preoped for the Operating Room for left
nephrectomy and L3 vertebrectomy with L2 to L4 fusion.  She
had this on 2118-4-29.  She tolerated the procedure well.
There were no intraoperative complications.  She was again
monitored in the Intensive Care Unit.  Postoperatively she
was fitted for a TLSO brace.  She remained on flat bed rest.
She was moving both lower extremities with good strength.
Her dressings were clean, dry and intact.  She had a chest
tube in place, which was draining serosanguinous fluid.  She
also had a JP drain in place.  JP drain was removed on
2118-5-2.  The patient's brace was brought in on 2118-5-2 and
the patient was out of bed on 2118-5-2.  Chest tube was
removed on 2118-5-3 and she was out of bed in her brace.
Her strength remained 5 out of 5 in all muscle groups.  She
was awake, alert and oriented times three and afebrile.  She
was transferred to the floor on 2118-5-3 and continued to do
well and continued to be followed by physical therapy and
occupational therapy and was found to be safely discharged to
home.  She was discharged to home on 2118-5-6 in stable
condition with follow up with Dr. Riddle on Tuesday the 17th
at 10:40 a.m. for staple removal.  She will follow up with
Dr. Mcdavid on 5-23 and with the oncology people on 5-18.

CONDITION ON DISCHARGE:  Stable.  She was afebrile.  Her
dressing was clean, dry and intact.

MEDICATIONS ON DISCHARGE:
1.  Percocet one to two tabs po q 4 hours prn.
2.  Nystatin 5 cc q.i.d. prn.
3.  Lasix 20 mg po q.d. times one day and then discontinued.
4.  Hydrocodone sustained release 30 mg po q.a.m.
5.  Hydrocodone 40 mg one tab at bedtime.
6.  Calcium carbonate 500 mg t.i.d.
7.  Phosphorus one packet b.i.d. for three days.
8.  Zolpidem tartrate 5 mg at h.s. prn.
9.  Lorazepam .5 mg q 4 to 6 hours prn.






                            Laura Clark, M.D.  M16484198

Dictated By:Imai
MEDQUIST36

D:  2118-5-6  11:48
T:  2118-5-6  12:13
JOB#:  Job Number 48401
"
"Unit No:  96586
Admission Date: 2157-1-29
Discharge Date: 2157-1-31
Date of Birth:  2157-1-29
Sex:  F
Service:  NB


HISTORY:  This infant was born at 34-6/7 weeks gestation with
an EDC of 2157-3-7 born to a 29-year-old G3, P0 (now 1)
mother with a prenatal screen as follows: Blood type A+,
antibody negative, RPR nonreactive, rubella immune, GBS
negative. Mother had a history of positive PPD on 2152-6-21 which she was treated for 9 months at that time and a
follow-up chest x-ray was negative. This pregnancy was
complicated by possible rupture of membrane on 2157-1-29. There was also some concern for maternal UTI on 2157-1-25 due to increased urinary frequency. The morning of
delivery, the mother was induced due to PPROM. Labor was
uncomplicated. The infant was vigorous at birth and received
only blow-by oxygen in the Delivery Room. She had Apgars of 7
and 8 at 1 and 5 minutes and was transferred to the NICU for
further management of prematurity.

FAMILY HISTORY:  Mom was treated for chlamydia in 2156-5-4
but otherwise noncontributory.

SOCIAL HISTORY:  Mom smokes 7 cigarettes daily. Father of the
baby is mother's boyfriend, Donald.

MEASURES AT BIRTH:  Weight of 2550 gm which is 75th
percentile, head circumference of 30 cm which is 10th-25th
percentile, length of 47 cm which is 50th-75th percentile.

DISCHARGE PHYSICAL EXAMINATION:  Active, alert female infant.
HEENT: Anterior fontanel soft and flat with mild __________
molding, small caput. Intact palate. Normal facies. Bilateral
red reflexes. Respiratory: Breath sounds clear and equal with
slight retractions, comfortable respirations. Cardiac: Normal
rate and rhythm. Normal S1/S2, no murmur. Normal pulses.
Brisk capillary refill. Abdomen: Soft and round with active
bowel sounds. Patent anus. GU: Normal preterm female.
Musculoskeletal: Normal spine. Straight spine. No sacral
dimple. Intact hips. Moves all extremities well. Neuro:
Normal reflexes, tone. Good suck.

SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Breath sounds are clear and equal. This
    infant has remained on room air since admission to the
    NICU. Has had no issues with apnea, bradycardia, or
    desaturations.
2. Cardiovascular: Infant has had no cardiovascular issues.
    Normal heart rates and blood pressures have been
    observed.
3. Fluid/electrolytes/nutrition: The infant was started on
    ad lib p.o. feedings with ___________ 20 cal/ounce. She
    is voiding and stooling normally. The weight at
    discharge is 2475 gm which is down 25 gm from birth
    weight. No electrolytes have been measured on this baby.
4. GI: Bilirubin was done at 40 hours of age and the
    bilirubin was 9.4/0.3. It is recommended to do a repeat
    bilirubin check on 2157-2-1 with the
    pediatrician.
5. Hematology: Mother's blood type is A+, DAT negative.
    Infant's blood typing was not done. There was a CBC
    drawn at birth to rule out sepsis. The hematocrit on
    that CBC was 62 with 285,000 platelets. There have been
    no further hematocrits or platelets measured. Infant has
    required no blood product transfusions.
6. Infectious disease: CBC and blood culture were screened
    on admission due to the PPROM and preterm labor. The CBC
    was benign. The infant received 48 hours of ampicillin
    and gentamycin which were subsequently discontinued when
    the blood culture remained negative at that time.
7. Neurology: The infant has maintained normal neurologic
    exam for gestational age.
8. Sensory:
    a.    Audiology: A hearing screen was performed with
     automated auditory brain stem responses and the infant
     passed in both ears.
9. Psychosocial: There are no active issues at this time.
    Parents are unmarried. Father of the baby is involved.
    If there are any psychosocial concerns, the social
    worker can be reached at 349-753-6799.

CONDITION ON DISCHARGE:  Good.

DISCHARGE DISPOSITION:  Home with parents.

PRIMARY PEDIATRICIAN:  Sharon Brunson, 439-643-4464.

CARE RECOMMENDATIONS:  Ad lib p.o. feedings of ___________ 20
cal/ounce. Medications: None.

IRON AND VITAMIN D SUPPLEMENTATION:
1. Iron supplementation is recommended for preterm and low
    birth weight infants until 12 months corrected age.
2. All infants fed predominantly breast milk should receive
    vitamin D supplementation at 200 international units
    which may be provided as a multivitamin preparation
    daily until 12 months corrected age.

__________ This infant has passed the car seat position
screening test.
State newborn screen was sent on 2156-10-31: Result is
pending.
Immunizations received: ____________.
Immunizations recommended: ____________.
A follow-up appointment is recommended with the pediatrician
on 2157-2-1.

DISCHARGE DIAGNOSES:
1. Prematurity born at 34-6/7 weeks gestation.
2. Sepsis ruled out.
3. Mild hyperbilirubinemia ongoing.



                    Dr. West  Dr. West E M.D P79910145

Dictated By:Mary
MEDQUIST36
D:  2157-1-31 13:01:51
T:  2157-1-31 14:05:08
Job#:  Job Number 76433
"
"Admission Date:  2130-4-14     Discharge Date:  2130-4-17
Date of Birth:   2082-12-11     Sex:  M
Service:  #58
HISTORY OF PRESENT ILLNESS:  Mr. Jefferson is a 47 year-old man
with extreme obesity with a body weight of 440 pounds who is
5'7"" tall and has a BMI of 69.  He has had numerous weight
loss programs in the past without significant long term
effect and also has significant venostasis ulcers in his
lower extremities.  He has no known drug allergies.
His only past medical history other then obesity is
osteoarthritis for which he takes Motrin and smoker's cough
secondary to smoking one pack per day for many years.  He has
used other narcotics, cocaine and marijuana, but has been
clean for about fourteen years.
He was admitted to the General Surgery Service status post
gastric bypass surgery on 2130-4-14.  The surgery was
uncomplicated, however, Mr. Jefferson was admitted to the Surgical
Intensive Care Unit after his gastric bypass secondary to
unable to extubate secondary to a respiratory acidosis.  The
patient had decreased urine output, but it picked up with
intravenous fluid hydration.  He was successfully extubated
on 4-15 in the evening and was transferred to the floor
on 2130-4-16 without difficulty.  He continued to have
slightly labored breathing and was requiring a face tent mask
to keep his saturations in the high 90s.  However, was
advanced according to schedule and tolerated a stage two diet
and was transferred to the appropriate pain management.  He
was out of bed without difficulty and on postoperative day
three he was advanced to a stage three diet and then slowly
was discontinued.  He continued to use a face tent overnight,
but this was discontinued during the day and he was advanced
to all of the usual changes for postoperative day three
gastric bypass patient.  He will be discharged home today
postoperative day three in stable condition status post
gastric bypass.
DISCHARGE MEDICATIONS:  Vitamin B-12 1 mg po q.d., times two
months, Zantac 150 mg po b.i.d. times two months, Actigall
300 mg po b.i.d. times six months and Roxicet elixir one to
two teaspoons q 4 hours prn and Albuterol Atrovent meter dose
inhaler one to two puffs q 4 to 6 hours prn.
He will follow up with Dr. Morrow in approximately two weeks as
well as with the Lowery Medical Center Clinic.
                          Kevin Gonzalez, M.D.  R35052373
Dictated By:Dotson
MEDQUIST36
D:  2130-4-17  08:29
T:  2130-4-18  08:31
JOB#:  Job Number 20340"