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notes_small.csv

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+PARSED
+"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"
+"Admission Date:  2107-11-13              Discharge Date:   2107-11-15
+
+Date of Birth:  2078-9-5             Sex:   M
+
+Service: EMERGENCY
+
+Allergies:
+No Known Allergies / Adverse Drug Reactions
+
+Attending:Annetta
+Chief Complaint:
+DKA
+
+Major Surgical or Invasive Procedure:
+None
+
+History of Present Illness:
+Mr. Abel is a 29 year old man with h/o Type I DM, 10 prior
+admissions for DKA since 1-4, who presents with SOB/chest
+discomfort, found to be in DKA.
+
+The patient was at work today when he started feeling dyspnea on
+exertion and substernal chest discomfort. CP worsened with deep
+breaths. No difference with change in position. FS at that time
+was 491, so the patient gave himself Humalog 7units. Repeat FS
+369. He drove himself to the ED for further evaluation.
+
+Of note, the patient was just admitted to Sprague Clinic 4 days prior in DKA, symptoms of N/V, discharged the
+following day without any changes to his prior regimen. He had
+been on insulin pump in the past, but was discontinued in 1-4.
+Just restarted on insulin pump 10 days prior to this admission -
+basal rate 0.75units/hr with bolus dosing at mealtime. Follows
+with Dr. Rothwell as an outpatient, last seen on 2107-11-4 and
+started on insulin pump at that time.
+
+In the ED, initial vs were: 98.4 100 112/72 15 100% RA. Chest
+discomfort resolved on arrival to the ED. Initial FS was >500,
+with anion gap of 22, urine ketones 150. Patient was given IVF -
+2LNS, 1L IVF with K, and started on 1L D5NS; started on insulin
+gtt. Repeat lytes showed improved gap from 22 -> 18.
+
+On the floor, the patient is currently comfortable. Only
+complaint is that he is hungry. No fevers, chills, cough, sore
+throat, N/V, abdominal pain, dysuria. SOB and CP are still
+resolved.
+
+Past Medical History:
+- Type I DM, diagnosed 2096, frequent hospitalizations with DKA
+- Diabetic cataract left eye s/p phacoemulsification with
+posterior chamber lens implant 2098.
+- Senile cataract right eye s/p phacoemulsification with
+posterior chamber lens implant 2099.
+- R shoulder subluxation
+
+Social History:
+- Tobacco: 10 cigarettes/day x 3 years
+- Alcohol:  occasional
+- Illicits:  none
+The patient works as a line cook at House of Blues.
+
+
+Family History:
+Diabetes mellitus Type II in his father, paternal grandfather,
+paternal aunts and uncles and maternal aunt; maternal GF/GM both
+died of heart failure
+
+
+Physical Exam:
+Vitals: T: 96.8 BP: 120/66 P: 82 R: 13 O2: 100%RA
+General: Alert, oriented, no acute distress
+HEENT: Sclera anicteric, MMM, oropharynx clear
+Neck: supple, JVP not elevated, no LAD
+Lungs: Clear to auscultation bilaterally, no wheezes, rales,
+rhonchi
+CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
+gallops
+Abdomen: soft, non-tender, non-distended, bowel sounds present,
+no rebound tenderness or guarding, no organomegaly
+GU: no foley
+Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
+edema
+Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
+intact in all extremities
+
+
+Pertinent Results:
+Admission labs:
+2107-11-13 04:30PM   WBC-6.0 RBC-4.58* HGB-14.4 HCT-40.9 MCV-89
+MCH-31.4 MCHC-35.1* RDW-11.7
+2107-11-13 04:30PM   NEUTS-69.7 LYMPHS-26.3 MONOS-2.7 EOS-0.9
+BASOS-0.4
+2107-11-13 04:30PM   PLT COUNT-271#
+2107-11-13 04:30PM   PT-10.6 PTT-22.1 INR(PT)-0.9
+2107-11-13 04:37PM   PH-7.26*
+2107-11-13 04:37PM   GLUCOSE-GREATER TH LACTATE-1.8 NA+-130*
+K+-4.9 CL--96 TCO2-12*
+2107-11-13 04:37PM   freeCa-1.19
+2107-11-13 04:30PM   GLUCOSE-575* UREA N-23* CREAT-1.3*
+2107-11-13 05:26PM URINE  COLOR-Straw APPEAR-Clear SP Tucker-1.021
+2107-11-13 05:26PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
+GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
+LEUK-NEG
+
+EKG: NSR @ 80bpm, nl axis and intervals, diffuse STE, more
+pronounced than prior in 9-4.
+
+Discharge labs:
+2107-11-15 05:54AM BLOOD WBC-7.2 RBC-4.72 Hgb-14.9 Hct-41.8 MCV-89
+MCH-31.5 MCHC-35.6* RDW-11.9 Plt Ct-276
+2107-11-15 05:54AM BLOOD Plt Ct-276
+2107-11-15 05:54AM BLOOD Glucose-67* UreaN-17 Creat-0.9 Na-143
+K-3.7 Cl-104 HCO3-26 AnGap-17
+2107-11-15 05:54AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.8
+
+Brief Hospital Course:
+Mr. Abel is a 29 year old man with h/o DM1, frequent
+hospitalizations for DKA, recently restarted on insulin pump,
+who was admitted in DKA.
+.
+#. DKA: Patient admitted for the 11th time this year with DKA.
+Recently started on insulin pump, now with his second admission
+in 10 days; insulin dosing did not appear to be adequate. No
+signs or symptoms of infection as a trigger at this time, though
+patient later had a persistent cough that was treated with
+azithromycin.
+On admission, patient was put on a regular insulin drip, and
+started on D5 1/2NS when glucose came down <200. The next
+morning, he was restarted on his insulin pump at a higher basal
+dose.
+The second day of admission, there was some confusion on two
+levels. The patient misunderstood the calorie counts in the menu
+and gave himself very low amounts of insulin based on his
+calorie counting scale. His glucose meter was also poorly
+calibrated and was giving finger stick readings about 150 lower
+than actual. He was hyperglycemic to the 400s, but did not have
+recurrent acidosis. His glucose levels subsequently improved.
+The next day we spoke with his outpatient endocrinologist Dr.
+Rothwell (114-594-2840), who said that he had only met the
+patient once. He has few insulin pump patients, so the decision
+was to have the patient return to Hughes for further follow-up.
+He will see Dr. Ray the day after discharge to re-establish
+care with him.
+.
+#. Cough: Patient had a productive cough. CXR negative. The
+decision was made to treat him with azithromycin for a suspected
+upper-respiratory tract infection.
+.
+#. ARF: Patient with Cr 1.3 on admission, baseline Cr 1.0.
+Improved with fluid resuscitation.
+
+Medications on Admission:
+Insulin - on pump since 2107-11-4, basal rate 0.75units/hr, bolus
+dosing for meals
+
+Discharge Medications:
+1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY
+(Daily) for 2 days.
+Disp:*2 Tablet(s)* Refills:*0*
+2. Burke Industries Insulin Pump  Sig: One (1)   once a day.
+3. One Touch Ultra Test     Strip Sig: One (1) strip
+Miscellaneous four times a day.
+4. Humalog 100 unit/mL Solution Sig: As directed units
+Subcutaneous four times a day: Use with insulin pump per
+directions.
+Discharge insulin pump settings:
+
+Basal Rates:
+  Midnight - midnight:  1.3 Units/Hr
+Meal Bolus Rates:
+  Breakfast = 1:8
+  Lunch = 1:8
+  Dinner = 1:8
+  Snacks = 1:8
+High Bolus:
+  Correction Factor = 1:50
+  Correct To mg/dL
+
+Discharge Disposition:
+Home
+
+Discharge Diagnosis:
+Diabetic ketoacidosis
+Type I diabetes
+
+Discharge Condition:
+Mental Status: Clear and coherent.
+Level of Consciousness: Alert and interactive.
+Activity Status: Ambulatory - Independent.
+
+Discharge Instructions:
+You were admitted with dangerously high blood sugar levels and
+ketoacidosis. Your blood sugar levels improved with a continuous
+insulin infusion and a lot of IV fluids. Your insulin pump was
+restarted at a higher level, and you are now safe to go home.
+
+You will need to follow your blood sugar very closely over the
+next couple of days to make sure that your insulin pump is
+properly titrated.
+
+Your only medications are to continue using your insulin pump
+and to take azithromycin for 2 more days.
+
+Followup Instructions:
+Please see Dr. Ray, at Hughes Diabetes Center, tomorrow,
+11-15, at 3pm. You can call (250-886-7061 if you need
+to make changes to that appointment.
+
+Please follow-up with your primary care doctor, Dr Lareau,
+within the next 2 weeks. You can call his office at
+314-618-2706.
+
+
+Completed by:2107-11-16"
+"Admission Date:  2180-5-18              Discharge Date:   2180-5-25
+
+Date of Birth:  2118-11-28             Sex:   F
+
+Service: NEUROSURGERY
+
+Allergies:
+No Known Allergies / Adverse Drug Reactions
+
+Attending:Joel
+Chief Complaint:
+confusion
+
+
+Major Surgical or Invasive Procedure:
+L Craniotomy for evacuation of L SDH
+
+
+History of Present Illness:
+This is a 61 year old woman without significant PMH who
+presented to her PCP's office after becoming confused at work.
+She remembers having a fall two weeks prior to presntation. An
+MRI Brain was performed which revealed a large subacute left
+SDH. She was sent to Reed Memorial Hospital ED and subsequently
+transferred to Lorenzo Hospital. Neurosurgical consultation requested for
+evaluation and treatment.
+She states that she fell two weeks ago remembers hitting her
+head
+but does not recall which side. She does not think she is
+confused but her co-workers believe that she is. She states that
+her friends thought her walking was impaired. Otherwise she
+reports no headache. She does say that she had trouble with her
+right hand when writing. She denies seizure like
+activity, LOC, fever, chills, Nausea, vomiting, chest pain or
+pressure, sob, or weakness in other extremities.
+
+
+Past Medical History:
+rheumatoid arthritis, rectal bleeding, HTN, seasonal
+allergies
+
+
+Social History:
+She works for the city of Lakeview, married, husband is currently
+ill. Denies tobacco,etoh, drugs
+
+
+Family History:
+non-contributory
+
+
+Physical Exam:
+On Admission:
+O: T:  BP: 130/60   HR: 92   R 18  O2Sats 99% 3L
+Gen: WD/WN, comfortable, NAD.
+HEENT: Pupils: 4 to 2mm equal.  EOMs Intact no nystagmus
+Neck: Supple.
+Lungs: CTA bilaterally.
+Cardiac: RRR. S1/S2.
+Abd: Soft, NT, BS+
+Extrem: Warm and well-perfused.
+
+Neuro:
+Mental status: Awake and alert, cooperative with exam with mild
+inattentiveness. Orientation: Oriented to person, place, and
+date. Language: Speech fluent with good comprehension and
+repetition.
+Naming intact. No dysarthria or paraphasic errors.
+
+Cranial Nerves:
+I: Not tested
+II: Pupils equally round and reactive to light, 4mm to 2
+mm bilaterally. Visual fields perceived as full although
+inattentive to task at times.
+III, IV, VI: Extraocular movements intact bilaterally without
+nystagmus.
+V, VII: Facial strength and sensation intact and symmetric.
+VIII: Hearing intact to voice.
+IX, X: Palatal elevation symmetrical.
+Dr. Brown: Sternocleidomastoid and trapezius normal bilaterally.
+XII: Tongue midline without fasciculations.
+Motor: tone increased b/l lower extremities. No abnormal
+movements,
+tremors. no drift noted. Motor impersistence.  Strength was full
+with the following exceptions, has b/l tricep 4-25, IP's 5-/5 and
+Hamstrigs 5-/5. The hands have significant pain and rheumatic
+changes and finger extension and wrist extension were not tested
+adequately.
+Sensation: Intact to light touch bilaterally.
+Reflexes: were grade 3 throughout.
+Toes upgoing bilaterally
+
+Gait: able to get up and out of bed with minimal assistance,
+unsteady gait with swaying backward upon standing.
+
+On Discharge: PERRLA, AAx O to person, hospital, Lakeview, time.
+No word finding difficulties. Right pronator drift. LE's full
+strength. RUE strength is 4- to 4-25 and LUE is 4 to 4+/5.
+
+Pertinent Results:
+CT HEAD W/O CONTRAST 2180-5-18
+Evolving large left vertex subdural hematoma with rightward
+subfalcine herniation and moderate effacement of the left
+lateral ventricle.   Allowing for differences in technique, the
+findings are little changed since the 14:11 MRI examination.
+
+CT head 2180-5-19
+1. Status post left craniotomy with evacuation of large subdural
+hematoma.  Post-surgical changes with bilateral pneumocephalus,
+left more than right with interval decrease of rightward shift
+of normally midline structures.
+2. No new focus of hemorrhage. Ventricles are stable in size.
+
+
+CT head 2180-5-22
+1. Increased size of a left vertex subdural hematoma with
+increased
+neighboring sulcal effacement and slight increase in rightward
+subfalcine
+herniation.
+2. Increased hyperdense material subjacent to the craniotomy
+site indicative of interval bleeding since 2180-5-19.
+3. New minimal effacement of the quadrigeminal and suprasellar
+cisterns.
+4. Increased soft tissue swelling and subgaleal hematoma at the
+craniotomy
+site.
+5. Evolving focal left frontal infarct at the subfalcine
+herniation site.
+
+
+
+
+Brief Hospital Course:
+This is a 61 y/o woman who had a fall 2 weeks prior to admision,
+striking her head. She presents to the ED with confusion. Head
+CT revealed L SDH with significant midline shift. She was taken
+to OR emergently for a L side craniotomy for evacuation of SDH.
+Post operatively patient was transferred to ICU for recovery. On
+5-19, post op head CT showed minimal improvement of midline
+shift and pneumocephalus. On examination, patient was a&ox3, R
+triceps 4-25, otherwise she was intact. She was transferred to
+step down unit and PT/OT consulted.
+On 5-21 the patient was neurologically stable and dilantin level
+was therapeutic.
+On 5-22 a repeat head CT was performed which revealed an increase
+in MLS. Fluid and air was aspirated from the crani site at the
+bedside and she was placed on 100%O2 for pneumocephalus. Her
+exam improved and word finding difficulties resolved. She was
+sorking with PT and OT and was being screened for rehab. Her BUN
+elevated to 21 on 5-23 and IVF were restarted at 50cc/hr. Her Bun
+stabilized to 20 and she was discharged to rehab on 5-25.
+
+
+Medications on Admission:
+Amlodipine Besy-Benxapril 11-9, plaquenil 1 tab Self Memorial Hospital (250mg),
+naprosyn 500mg Self Memorial Hospital, prednisone 5mg daily
+
+
+Discharge Medications:
+1. insulin regular human 100 unit/mL Solution Sig: Two (2) units
+Injection ASDIR (AS DIRECTED).
+2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
+
+3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
+
+4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
+hours) as needed for pain or fever: max 4g/24 hrs.
+5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
+(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
+6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
+PO TID (3 times a day).
+7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
+day): hold for loose stools.
+8. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
+as needed for pain.
+9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
+Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
+constipation.
+10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
+(2 times a day): hold for loose stools.
+11. heparin (porcine) 5,000 unit/mL Solution Sig: 14428 (14428)
+units Injection TID (3 times a day).
+12. benazepril 10 mg Tablet Sig: Two (2) Tablet PO Daily ():
+Hold if SBP <105 or K> 4.5
+.
+
+
+Discharge Disposition:
+Extended Care
+
+Facility:
+Duncan Medical Center Martinez Memorial Hospital Rehabilitation and Nursing Center - Eerie
+
+Discharge Diagnosis:
+L SDH with midline shift
+
+
+Discharge Condition:
+Level of Consciousness: Alert and interactive.
+Activity Status: Ambulatory - Independent.
+Mental Status: Confused - always.
+
+
+Discharge Instructions:
+??????	Have a friend/family member check your incision daily for
+signs of infection.
+??????	Take your pain medicine as prescribed.
+??????	Exercise should be limited to walking; no lifting, straining,
+or excessive bending.
+??????	You may wash your hair only after sutures and/or staples have
+been removed. They should be removed on 5-27.
+??????	You may shower before this time using a shower cap to cover
+your head.
+??????	Increase your intake of fluids and fiber, as narcotic pain
+medicine can cause constipation. We generally recommend taking
+an over the counter stool softener, such as Docusate (Colace)
+while taking narcotic pain medication.
+??????	You may resume taking prednisone
+??????	If you were on a medication such as Coumadin (Warfarin), or
+Plavix (clopidogrel), or Aspirin, prior to your injury, you may
+safely resume taking after post-op review
+??????	You have been prescribed Dilantin (Phenytoin) for anti-seizure
+medicine, take it as prescribed and follow up with laboratory
+blood drawing in one week.  This can be drawn at your PCP??????s
+office, but please have the results faxed to 311-654-8171.
+??????	Clearance to drive and return to work will be addressed at
+your post-operative office visit.
+??????	Make sure to continue to use your incentive spirometer while
+at home, unless you have been instructed not to.
+
+CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
+FOLLOWING
+
+??????	New onset of tremors or seizures.
+??????	Any confusion or change in mental status.
+??????	Any numbness, tingling, weakness in your extremities.
+??????	Pain or headache that is continually increasing, or not
+relieved by pain medication.
+??????	Any signs of infection at the wound site: redness, swelling,
+tenderness, or drainage.
+??????	Fever greater than or equal to 101?????? F.
+
+
+Followup Instructions:
+Follow-Up Appointment Instructions
+
+??????You may return to the office in 7-30 days(from your date of
+surgery) for removal of your staples/sutures and/or a wound
+check. This can alos be done at rehab by 5-27.
+??????Please call (505-473-5282 to schedule an appointment with Dr.
+Wise, to be seen in 4 weeks.
+??????You will need a CT scan of the brain without contrast.
+
+
+                             Ashley Jerald MD I17811034
+
+Completed by:2180-5-25"
+"Admission Date:  2177-10-2              Discharge Date:   2177-10-30
+
+Date of Birth:  2120-8-4             Sex:   M
+
+Service: CARDIOTHORACIC
+
+Allergies:
+Patient recorded as having No Known Allergies to Drugs
+
+Attending:Johnny
+Chief Complaint:
+Epigastric discomfort and lethargy
+
+Major Surgical or Invasive Procedure:
+2177-10-6 Five Vessel Coronary Artery Bypass Grafting(LIMA to
+LAD, with vein grafts to first diagonal, second diagonal, obtuse
+marginal, and PDA), Mitral Valve Repair(30mm Annuloplasty Ring),
+with Insertion of an IABP.
+
+
+History of Present Illness:
+Mr. Gladys is a 57 year old male who presented to OSH in mid
+September with shortness of breath, gastric discomfort and
+fatigue. He ruled in for a ST elevation MI. Subsequent cardiac
+catheterization revealed severe three vessel coronary artery
+disease and an LVEF of 36%. Echocardiogram at that time was
+notable for an LVEF of 40% with inferior wall akinesis and
+moderate mitral regurgitation. Patient was declined for surgery
+at Starr Clinic(secondary to poor distal targets) and
+eventually transferred to the Wood Memorial Hospital for further evaluation and
+treatment.
+
+Past Medical History:
+Ischemic Cardiomyopathy, Coronary Artery Disease with inferior
+wall ST Elevation MI on 2177-9-30, Mitral Regurgitation,
+Hypertension, Type II Diabetes Mellitus(poorly controlled),
+Hyperlipidemia
+
+Social History:
+Denies tobacco and ETOH. He lives alone. He is a truck driver.
+
+Family History:
+Denies family history of premature coronary artery disease.
+
+Physical Exam:
+Admission
+HR 74 SR BP 126/62 RR 20 Sat 96% on 4L
+Neuro Arousable, follows commands with encouragement. MAE,
+strength 5/5 t/o. PERRL.
+CV RRR no M.R.G
+Lungs wheezes, crackles
+Abdomen soft/NT
+Extrem 1+ edema, warm 2+ pulses t/o
+no carotid bruits
+Discharge
+T 99.6  HR 76SR  BP104/60  RR22  O2sat 96%RA
+Neuro: Awake, moves rt side to command, left dense hemiparesis
+CV: RRR, sternum stable
+Pulm: course rhonchi
+Abdm: soft, NT/+BS
+Ext: left LE 3+ edema, Rt LE no edema
+
+Pertinent Results:
+COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
+2177-10-30 02:29AM    8.6 2.90* 8.3* 24.9* 86 28.8 33.5 16.0*
+281
+Source: Line-CVL
+  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
+2177-10-30 02:29AM        281
+Source: Line-CVL
+2177-10-30 02:29AM    20.5*1 65.6*   1.9*
+  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
+2177-10-30 02:29AM    150* 25* 1.2 137 3.8 99 30 12
+
+RADIOLOGY  Final Report
+CHEST (PORTABLE AP)  2177-10-29 1:30 PM
+CHEST (PORTABLE AP)
+Reason: dobhoff placement
+Choudhury Medical Center MEDICAL CONDITION:
+57 year old man with s/p CABG
+REASON FOR THIS EXAMINATION:
+dobhoff placement
+CHEST, SINGLE AP FILM
+History of CABG.
+Status post CABG. Distal end of feeding tube overlies body of
+stomach. There is cardiomegaly and a left pleural effusion with
+associated atelectasis in the visualized left lower lung. No
+pneumothorax. The left subclavian CV line has tip located over
+the proximal SVC.
+IMPRESSION: No definite pneumothorax. Left pleural effusion and
+associated atelectasis in left lower lobe, overall appearances
+being essentially unchanged since prior study of 2177-10-28.
+
+DR. Herbert Castaneda
+
+2177-10-2 10:30PM BLOOD WBC-10.5 RBC-5.03 Hgb-14.2 Hct-43.4
+MCV-86 MCH-28.2 MCHC-32.7 RDW-14.1 Plt Ct-273
+2177-10-2 10:30PM BLOOD PT-15.1* PTT-91.3* INR(PT)-1.4*
+2177-10-2 10:30PM BLOOD Glucose-364* UreaN-35* Creat-1.4* Na-133
+K-4.7 Cl-94* HCO3-27 AnGap-17
+2177-10-2 10:30PM BLOOD ALT-207* AST-93* LD(LDH)-531*
+AlkPhos-325* Amylase-35 TotBili-0.6
+2177-10-2 10:30PM BLOOD Albumin-3.3* Mg-2.5
+2177-10-2 10:49PM BLOOD Type-ART pO2-76* pCO2-36 pH-7.49*
+calTCO2-28 Base XS-4
+2177-10-2 10:49PM BLOOD Glucose-282* Lactate-1.6 Na-132* K-4.1
+Cl-94*
+2177-10-5 08:58PM BLOOD %HbA1c-12.4*
+2177-10-3 Non Contrast Head CT Scan:
+There is no evidence of intracranial hemorrhage, mass effect, or
+shift of normally midline structures. Dr. Butler-white matter
+differentiation is preserved. The ventricles are normal in size
+and symmetric. There is no evidence of acute major vascular
+territorial infarction. There are moderate cavernous carotid
+calcifications. There is complete opacification of the right
+maxillary sinus. The remaining paranasal sinuses and mastoid air
+cells are clear.
+2177-10-6 Intraoperative TEE:
+PRE-BYPASS:
+Pt requiring dobutamine infusion at 7.5
+1. No atrial septal defect is seen by 2D or color Doppler.
+2. There is mild to moderate global left ventricular hypokinesis
+(LVEF = 35-40 %), with basal to mid inferior and
+inferior-lateral akinesis. [Intrinsic left ventricular systolic
+function is likely more depressed given the severity of valvular
+regurgitation.].
+3. Right ventricular chamber size is normal. There is mild to
+moderate global right ventricular free wall hypokinesis.
+4. There are simple atheroma in the ascending aorta. The
+descending thoracic aorta is mildly dilated. There are simple
+atheroma in the descending thoracic aorta.
+5. There are three aortic valve leaflets. The aortic valve
+leaflets are mildly thickened. Trace aortic regurgitation is
+seen.
+6. The mitral valve leaflets are mildly thickened. Moderate to
+severe (3+) mitral regurgitation is seen, with noted centrally
+directed regurgitant jet. The mitral regurgitation vena
+contracta is >=0.7cm.
+7.The tricuspid valve leaflets are mildly thickened; there is
+mild to moderate (12-17+) tricuspid regurgitation.
+POST-BYPASS:
+Pt removed from cardiopulmonary bypass on vasopression,
+milrinone, epinephrine and norephinephrine infusions and
+placement of intra-aortic balloon pump.
+1. Pt s/p mitral valve annuloplasty. There is no mitral
+regurgitation.
+2. Biventricular function is improved. Right ventricular is
+normal sized and function has improved from moderate to mild
+dysfunction. Left ventricular function remains globally
+depressed; basal to mid inferior walls remain akinetic; there is
+improvement of anterior wall function.
+3. Aortic contours are intact post-decannulation. There is an
+intra-aortic balloon noted in the proper position.
+2177-10-15 Transthoracic ECHO:
+The left atrium is moderately dilated. There is mild symmetric
+left ventricular hypertrophy with normal cavity size. There is
+moderate regional left ventricular systolic dysfunction with
+akinesis of the inferior and inferolateral walls. The remaining
+segments contract normally (LVEF = 35-40 %). The aortic valve
+leaflets (3) are mildly thickened but aortic stenosis is not
+present. No aortic regurgitation is seen. The mitral valve
+leaflets are mildly thickened. A mitral valve annuloplasty ring
+is present. The mitral annular ring appears well seated and is
+not obstructing flow. No mitral regurgitation is seen. There is
+borderline pulmonary artery systolic hypertension. There is a
+very small pericardial effusion most prominent around the right
+atrium.
+2177-10-16 Cardiac Catheterization:
+1. Selective coronary angiography of this right dominant system
+demonstrated native 3 vessel coronary artery disease. The LMCA
+had
+diffuse mild disease. The LAD was occluded in the mid vessel.
+The LCX
+was occluded proximally. The RCA was occluded proximally. The
+SVG-PDA
+was patent with slow flow into a small PDA. The SVG-D1 was
+patent as was
+SVG-D2, both with slow flow into small distal vessels. The
+SVG-OM was
+patent with slow flow as well. The LIMA-LAD was patent. The LAD
+beyond
+the LIMA was diffusely small with slow flow.
+2. Limited resting hemodynamics were performed. The systemic
+arterial pressures were borderline low measuring 86/63mmHg.
+2177-10-20 Non contrast Head CT Scan:
+There is no sign for the presence of an intracranial hemorrhage.
+There is a question of a 1cm area of low density seen within the
+region of the right uncus, which did not appear to be present on
+the prior CT scan. If real, this finding could represent an area
+of developing infarction. No other definite interval changes are
+appreciated. There is no hydrocephalus or shift of normally
+midline structures.
+2177-10-21 MRA Brain:
+Multiple areas of restricted diffusion bilaterally including
+also the right cerebellar hemisphere as described above, areas
+of subacute ischemic changes extending from the posterior limb
+of the right internal capsule to the right, hippocampal area.
+These December are suggestive of subacute infarcts likely from
+an embolic source involving multiple vascular territories.
+
+
+
+
+Brief Hospital Course:
+Mr. Gladys was admitted to the cardiac surgical service. He
+remained pain free on intravenous Heparin and Nitroglycerin. He
+was initially evaluated by the Neurology service for an altered
+mental status, experiencing periods of unresponiveness,
+confusion and agitation/delirium. A head CT scan was
+unremarkable and his altered mental status was attributed
+metabolic encephalopathy. There was no evidence of stroke. Over
+the next several days from a cardiac standpoint, he gradually
+developed cardiogenic shock and required inotropic support.
+Given his critical condition, he was urgently brought to the
+operating room on 10-6 where Dr. Hess performed
+coronary artery bypass grafting and mitral valve repair. Given
+his low ejection fraction, an IABP was placed prior to weaning
+from cardiopulmonary bypass. For additional surgical details,
+please see seperate dictated operative note. Following the
+operation, he was brought to the CVICU in critical condition.
+His postoperative course will now be broken down into systems:
+
+CARDIAC: Initially required multiple inotropes for poor
+hemodynamics. Started on Amiodarone on postoperative day two for
+atrial and ventricular arrhythmias. The IABP was slowly weaned
+and eventually removed on postoperative day four without
+complication. He remained pressor dependent at that time.
+Cardioversion was performed on postoperative day six for
+episodes of atrial fibrillation associated with a decrease in
+SVO2. By postoperative seven, all inotropic support was weaned.
+Despite Amiodarone, he continued to experience atrial and
+ventricular arrhythmias. He went on to develop an episode of
+sustained ventricular fibrillation/torsades on postoperative day
+eight for which successfull defibrillation was performed.
+Amiodarone was discontinued and switched to Lidocaine. A calcium
+channel blocker was concomitantly initiated. The EP/cardiology
+services were consulted and recommended EPS with potential VT
+ablation. To rule out ischemia as the cause for ventricular
+tachycardia, cardiac catheterization was performed on 10-16 which showed patent grafts. Given ventricular arrhythmias,
+he was eventually started on Mexiletine.
+
+PULMONARY: Given critical condition, required prolonged
+mechanical ventilation. Eventually extubated on postoperative
+day nine. He was electively re-intubated for cardiac
+catheterization on 10-16, and re-extubated later that
+night. Unfortunatly, he went on to develop acute respiratory
+failure later that night and required reintubation. Bronchoscopy
+was performed on 10-17 which found patent airways without
+evidence of mucous plugs and only minimal scant secretions. A
+left sided chest tube was placed for pleural effusion. The
+effusion improved and the chest tube as removed.
+
+NEURO: Given his critical condition, had a prolonged period of
+sedation. Following his initial extubation, he awoke
+neurologically intact. Following his second re-extubation on
+postoperative day 14, he was noted to have new onset left
+hemiparesis and left sided neglect. Neurology was consulted
+while head CT scans and MR Donald Scrivens consistent with
+embolic stroke(see result section). Heparin and coumadin were
+started.
+
+RENAL: Developed oliguric acute renal failure. Creatinine peaked
+to 2.9 on postoperative day eight. The renal service was
+consulted and attributed his renal insufficiency to pre-renal
+etiology. Renal function gradually improved and he responded
+nicely to diuretics.
+
+ENDOCRINE: Initially maintained on Insulin drip. Transitioned to
+lantus insulin.
+
+HEME: Mild postoperative anemia and was intermittently
+transfused to maintain hematocrit near 30%.
+
+ID: Remained afebrile with no evidence of infection.
+
+GI: Bedside swallow on 10-22 recommended continuing NPO/tube
+feeding as he was not consistently awake enough to safely
+attempt anything by mouth. Tolerating tube feedings.
+
+Skin: A hematoma formed at an ex-chest tube site on his left
+flank and began bleeding with anticoagulation. It was sutured on
+10-26 and subsequently improved.
+
+
+Medications on Admission:
+Intravenous Nitroglycerin
+Docusate Sodium 100 Showalter Medical Center
+Metoprolol 75 Showalter Medical Center
+Pantoprazole 40 qd
+Aspirin 325 qd
+Lisinopril 2.5 qd
+Simvastatin 40 qd
+Glargine 20 units qhs
+RISS
+
+Discharge Medications:
+1. Simvastatin 40 mg Tablet Showalter Medical Center: One (1) Tablet PO DAILY
+(Daily).
+2. Aspirin 81 mg Tablet, Chewable Showalter Medical Center: One (1) Tablet, Chewable
+PO DAILY (Daily).
+3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Showalter Medical Center: Two
+(2) Puff Inhalation Q4H (every 4 hours).
+4. Fluticasone 110 mcg/Actuation Aerosol Showalter Medical Center: Two (2) Puff
+Inhalation Showalter Medical Center (2 times a day).
+5. Docusate Sodium 50 mg/5 mL Liquid Showalter Medical Center: One (1)  PO BID (2
+times a day).
+6. Carvedilol 12.5 mg Tablet Showalter Medical Center: Two (2) Tablet PO BID (2 times
+a day). Tablet(s)
+7. Mexiletine 150 mg Capsule Showalter Medical Center: One (1) Capsule PO Q8H (every
+8 hours).
+8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR Kenison: One (1)
+Tablet,Rapid Dissolve, DR Kenison DAILY (Daily).
+9. Bisacodyl 10 mg Suppository Kenison: One (1) Suppository Rectal
+DAILY (Daily).
+10. Sodium Chloride 0.65 % Aerosol, Spray Kenison: 12-17 Sprays Nasal
+QID (4 times a day) as needed.
+11. Ipratropium Bromide 0.02 % Solution November: One (1)  Inhalation
+Q6H (every 6 hours) as needed.
+12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1)
+ Inhalation Q4H (every 4 hours) as needed.
+13. Artificial Tear with Lanolin 0.1-0.1 % Ointment November: One (1)
+Appl Ophthalmic PRN (as needed).
+14. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution November: One (1)
+ Inhalation Q6H (every 6 hours) as needed.
+15. Warfarin 1 mg Tablet November: as directed Tablet PO DAILY
+(Daily): target INR 2-2.5
+Pt to receive 7.5mg on 10-30.
+16. Lisinopril 5 mg Tablet April: One (1) Tablet PO DAILY (Daily).
+
+17. Furosemide 80 mg Tablet April: One (1) Tablet PO BID (2 times
+a day).
+
+
+Discharge Disposition:
+Extended Care
+
+Facility:
+Blackwater Senior Care - Thomas Memorial Hospital
+
+Discharge Diagnosis:
+- Ischemic Cardiomyopathy, ST Elevation Myocardial Infarction,
+Coronary Artery Disease, Mitral Regurgitation, Cardiogenic Shock
+- s/p Urgent CABG and Mitral Valve Repair on IABP
+- Postoperative Stroke
+- Postoperative Acute Respiratory Failure
+- Postoperative Acute Renal Failure
+- Postoperative Atrial Fibrillation/Flutter
+- Postoperative Ventricular Tachycardia
+- Postoperative Bradycardia
+- Postoperative Anemia
+- Postoperative Pleural Effusion
+- Hypertension
+- Hyperlipidemia
+- Type II Diabetes Mellitus
+
+
+Discharge Condition:
+Stable.
+
+
+Discharge Instructions:
+1)Please shower daily. No baths. Pat dry incisions, do not rub.
+2)Avoid creams and lotions to surgical incisions.
+3)Call cardiac surgeon if there is concern for wound infection.
+4)No lifting more than 10 lbs for at least 10 weeks from
+surgical date.
+
+Dineenp Instructions:
+Dr. Smith 4-5 weeks, please call for appt
+Cardiology clinic-Dr Kenison (EP) in 2-16 weeks, please call
+for appt
+
+
+
+Completed by:2177-10-30"
+"Name:  Kelli,Elizabeth                     Unit No:   66109
+
+Admission Date:  2183-7-12              Discharge Date:   2183-7-27
+
+Date of Birth:  2127-9-2             Sex:   F
+
+Service: MED
+
+Allergies:
+Percocet / Codeine / Robaxin / Lomotil / Vancomycin And
+Derivatives
+
+Attending:Courtney
+Chief Complaint:
+Fatique, fever
+
+Major Surgical or Invasive Procedure:
+surgical removal of port.
+
+
+Brief Hospital Course:
+See prior addenda
+
+Discharge Medications:
+additional d/c medication, insulin:
+
+Lantus(Glargine) - 13 Units q evening, Loftus Memorial Hospital.
+
+Discharge Disposition:
+Extended Care
+
+Facility:
+Blackwater House Nursing Home - Thundera
+
+Discharge Diagnosis:
+Line sepsis from infected Lt. port; MRSA bacteremia
+
+
+Discharge Condition:
+Good
+
+                             John Sorrell MD J60211121
+
+Completed by:2183-7-27"
+"Admission Date:  2135-6-22       Discharge Date:  2135-7-2
+
+Date of Birth:   2076-4-4       Sex:  M
+
+Service:
+
+HISTORY OF PRESENT ILLNESS:  The patient is a 59-year-old
+male with a history of metastatic melanoma to bowel and known
+pulmonary and CNS metastases status post craniotomy with
+resection of the brain metastases.  The patient presented
+with a three day history of intermittent worsening and crampy
+abdominal pain in the lower quadrants, worse on the right
+than on the left.  The pain was described as severe.  The
+patient had a bowel movement until the day prior to
+admission.  KUB on arrival in the Emergency Department showed
+dilated loops of small bowel with air fluid levels.  A CT
+scan obtained shortly thereafter showed two large mesenteric
+masses with erosion into small bowel and free perforation of
+the more proximal segment of small bowel, as well as
+mechanical mid small bowel obstruction.
+
+PAST MEDICAL HISTORY:
+1.  Metastatic melanoma with metastases to the lung, brain,
+bowel, left flank
+
+MEDICATIONS:
+1.  Nexium 40 mg po qd
+2.  Flomax
+3.  Flonase
+4.  Compazine
+5.  Ambien 10 mg
+6.  Quinine 260 mg
+7.  Prednisone 10 mg po
+8.  50 mcg fentanyl patch
+
+The patient had recently been on his first week to Taxol
+dexamethasone therapy and had also been through four cycles
+of IL-2/temozolomide for his metastatic melanoma.
+
+ALLERGIES:  The patient has no known drug allergies.
+
+SOCIAL HISTORY:  The patient had smoked one pack per day for
+about 20 years, but quit 20 years ago.
+
+PHYSICAL EXAM:
+VITAL SIGNS:  Temperature 98.8??????, blood pressure 120/70, pulse
+117, respiratory rate 20, O2 saturation 96% on room air.
+GENERAL:  The patient was awake and comfortable and appeared
+well nourished.
+HEAD, EARS, EYES, NOSE AND THROAT:  No jugular venous
+distention, no palpable nodes.  Oropharynx was clear.
+NECK:  Supple.
+HEART:  S1, S2, tachycardic with no murmurs, rubs or gallops.
+LUNGS:  Clear to auscultation bilaterally.
+ABDOMEN:  Distended, nontender, no hepatosplenomegaly.  There
+were decreased bowel sounds.  Abdomen was tense and was a 7
+cm subcutaneous mass on the left flank.
+EXTREMITIES:  There was no lower extremity edema, cyanosis or
+clubbing.
+
+LABS:  White cell count 9.8, hematocrit 13.8, platelets 947.
+PT 12.8, PTT 21.5, INR 1.1.  Chem-7 - sodium 136, potassium
+4.8, chloride 98, bicarbonate 23, BUN 23, creatinine 0.6,
+glucose 146, calcium 8.7, magnesium 1.8, phosphorus 4.2.
+
+HOSPITAL COURSE:  The patient arrived in the hospital on the
+evening of 6-22 and evaluation was initiated.  The patient
+was taken to the Operating Room late in the night of 6-22
+where, per the Operating Room note, tumors were discovered in
+the ileum and jejunum with free perforation of both lesions.
+The patient was then transferred to the Intensive Care Unit.
+The patient was started on ampicillin, levofloxacin and
+Flagyl.
+
+On postoperative day #2, which was 2135-6-25, the patient was
+started on TPN.  His antibiotics were continued.  On
+postoperative day #3, the patient was noted to have a
+slightly increased temperature to 100.2??????.  He was pan
+cultured given the fact he had recently been on steroids.
+His central line was also changed.  During the course of the
+day, the patient was agitated at one point and pulled his
+A-line.  Haldol was prescribed.
+
+On postoperative day #4, the patient appeared to be less
+confused.  He was transferred to the floor with a sitter.  By
+postoperative day #5, while the patient was on the floor, he
+was appearing much more lucid, communicating appropriately
+and the sitter was discontinued.  The patient was continued
+on total parenteral nutrition.  Because of continued increase
+in white cell count from 14.3 on postoperative day #4 to 16.0
+on postoperative day #5, the patient was sent for an
+abdominal CT.  Although no abscess was identified that could
+explain the patient's increase in white cell count, the
+patient was noted to have developed mural thrombus in his
+abdominal aorta and in the left iliac artery.  The patient
+was also noted to develop some new bilateral pleural
+effusions with some barium in the left lung base.  On being
+notified of these findings, the surgical team immediately
+consulted the patient's neuro-oncologist and oncologist team
+for advice on the propriety of placing the patient on
+anticoagulation.
+
+The patient was seen by his neuro-oncologist on postoperative
+day #6, which was the 4-29.  The patient's
+neuro-oncologist requested head CT be obtained to rule out
+any new brain metastases with bleeding because this would
+determine the patient's suitably for anticoagulation.  The
+head CTs were negative and per neuro-oncology, there was no
+contraindication to anticoagulating the patient.  The patient
+was seen by his oncologist team also on postoperative day #6.
+Oncology was of the opinion of the patient, was unsuitable
+for anticoagulation with Coumadin or heparin but that aspirin
+could be initiated.  The patient was therefore started on
+aspirin.
+
+The patient's steroids were also tapered beginning on
+postoperative day #7.  His fluconazole was discontinued.  At
+the suggestion of the patient's oncology team, the surgery
+team also transfused the patient with 1 unit packed red blood
+cells on postoperative day #8 for borderline low hematocrit
+of 26.1.  On postoperative day #7, the patient's diet was
+changed from NPO to sips.  The patient tolerated this well
+and so on postoperative day #8, the patient was advanced to a
+clear liquid diet and his TPN was discontinued.  By the
+evening of postoperative day #8, the patient was able to
+tolerate a regular diet and on the day of discharge, which
+was 2135-7-2, the patient had a regular breakfast without any
+problems.  Lindsey is to be discharged home with visiting nurse
+assistant for wound care.  Mr. Jeannette continues to have an
+open vertical incision in the midline of his abdomen that
+would require wet to dry dressings twice a day.
+
+DISCHARGE MEDICATIONS:
+1.  Flomax
+2.  Flonase
+3.  Compazine
+4.  Ambien
+5.  Quinine
+6.  Prednisone 10 mg po qd
+7.  Protonix 40 mg po bid
+8.  Percocet 5 1 to 2 tablets by mouth every 4 to 6 hours
+9.  Levofloxacin 500 mg po qd x5 more days
+
+FOLLOW UP:  The patient is to follow up with oncology on 7-18.  The patient is to call Dr.Ervin office for
+follow up appointment this coming week.
+
+
+
+
+                            Barbara Sundberg, M.D.  W92784896
+
+
+Dictated By:George
+MEDQUIST36
+
+D:  2135-7-2  10:51
+T:  2135-7-2  11:14
+JOB#:  Job Number 18599
+"
+"Admission Date:  2161-12-15     Discharge Date:  2161-12-22
+
+Date of Birth:   2118-1-10     Sex:  F
+
+Service:
+
+DIAGNOSIS:
+Tracheal bronchial malacia.
+
+HISTORY OF PRESENT ILLNESS:  The patient is a delightful 43
+year-old woman who was found to have tracheal bronchial
+malacia and has suffered from years of dyspnea on exertion,
+persistent tracheal bronchitis and recurrent infections. She
+is therefore admitted to undergo a right thoracotomy and
+tracheoplasty.
+
+HOSPITAL COURSE:  The patient is admitted to the hospital and
+underwent minimally invasive muscle sparring oscillatory
+triangle thoracotomy with tracheal bronchoplasty on the day
+of admission.  She did well and was discharged without
+problems.
+
+
+
+
+
+
+                          Diane Lewis, M.D.  C45888251
+
+Dictated By:Vail
+
+MEDQUIST36
+
+D:  2162-4-5  05:00
+T:  2162-4-7  09:38
+JOB#:  Job Number 33135
+"
+"Admission Date:  2163-11-21              Discharge Date:   2163-12-1
+
+Date of Birth:  2086-12-16             Sex:   M
+
+Service: MEDICINE
+
+Allergies:
+Patient recorded as having No Known Allergies to Drugs
+
+Attending:Flossie
+Chief Complaint:
+CHF, ARF, Mediastinal lymphadenopathy
+
+Major Surgical or Invasive Procedure:
+Bronchoscopy x 2
+Mediastinoscopy with lymph node biopsy
+
+History of Present Illness:
+76M initially went to Davis Hospital hospital with L flank and sent
+home with narcs.  Represented with DOE, weight gain and L flank
+pain.  He reports that he has had intermittent DOE for year but
+notice a sharp increase in his weight over a period of 10 days.
+He gained 8-10lbs with associated LE swelling, but without
+medication noncompliance, dietary changes, chest pain,
+orthopnea, PND.  This happened at the beginning of July and
+his Lasix was increased from 40 to 60 daily.  He also had a
+holter revealing afib (rate 40-100), nuclear stress
+(2163-11-1)without ischemia and normal ECHO on 2163-11-3 (mild AS,
+mild MR).  Upon arrival to the ED he was found to be hypotensive
+with hyperkalemia and ARF (Cr ~4 from basline of 1.2)  He was
+sent to the floor, diuresed and then sent to the ICU after he
+was hypotensive requiring dopamine and vasopressin.  He had a
+Swan-Ganz catheter placed on 11-19 and had renally dosed
+dopamine.  He was thought to be fluid overloaded and had a
+transudative thoracentesis (amount removed unknown).  He was
+aggressively diuresed with Lasix and renally dosed Dopamine. His
+renal function improved prior to transfer.
+Swan numbers:
+RA: 25
+RV: 55/20/10
+PA: 55/25
+PCW: 26
+His L flank pain was evaluated with a CT Abdomen and he was
+found to have L nephrolithiasis and an exophytic cyst on the
+lower pole of the L kidney.  His pain has been controlled with
+narcotics.
+He had also been recieving  Zyvox for presumed pneumonia and
+solumedrol 60 mg q6h for presumed COPD.
+He was transferred for evaluation of his mediatinal LAD.  This
+has been watched for seveal years and he has two non-FDG avid
+PET CTs, most recently in 2163-6-26.  He denies any B symptoms.
+He does have decreased appetite, but has been active with
+outside hobbies including golf and curling.  The thoracics
+service was contactTammy for this evaluation and it was suggested
+that the patient be admitted to the MICU given his underlying
+medical problems.
+
+
+Past Medical History:
+PAST MEDICAL HISTORY:
+====================
+AF, on coumadin at home
+CRI Cr:1.6
+Chronic Anemia
+CHF EF
+Bladder CIS s/p BCG washout in 10/2163
+Colonic dysplastic lesions on bx
+OSA- unable to tolerate CPAP
+low grade NHL with diffuse stable LAD
+AS
+R popliteal artery endarterectomy
+uretral stent
+Gout
+PVD
+L CEA 2159
+UGIB 2161
+LLL lobectomy in 2135
+Nephrolithiasis
+
+
+Social History:
+EtOH: 2 martinis daily
+Tobacco: quit 1ppd 25 yrs ago
+outside hobbies included golf and curling
+
+
+Family History:
+no history of malignancy
+
+Physical Exam:
+Tmax: 35.9 ??????C (96.6 ??????F)
+
+Tcurrent: 35.9 ??????C (96.6 ??????F)
+
+HR: 74 (67 - 75) bpm
+
+BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg
+
+RR: 20 (20 - 24) insp/min
+
+SpO2: 96%
+
+Heart rhythm: AF (Atrial Fibrillation)
+Physical Examination
+
+General Appearance: Well nourished, No acute distress
+
+Eyes / Conjunctiva: PERRL
+
+Head, Ears, Nose, Throat: Normocephalic, MMM
+
+Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
+Cervical adenopathy
+
+Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
+III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at
+base
+
+Peripheral Vascular: (Right radial pulse: Present), (Left radial
+pulse: Present), (Right DP pulse: Present), (Left DP pulse:
+Present)
+
+Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
+Crackles : bilateral bases)
+
+Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present,
+Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds
+
+Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t)
+Clubbing
+
+Skin:  Not assessed
+
+Neurologic: Responds to: Not assessed, Movement: Not assessed,
+Tone: Not assessed
+
+
+Pertinent Results:
+2163-11-22 Echo: The left atrium is elongated. The right atrium is
+markedly dilated. The right atrial pressure is indeterminate.
+There is moderate symmetric left ventricular hypertrophy. The
+left ventricular cavity size is normal. Left ventricular
+systolic function is hyperdynamic (EF>75%). Right ventricular
+chamber size and free wall motion are normal. The aortic root is
+mildly dilated at the sinus level. The ascending aorta is mildly
+dilated. The aortic valve leaflets (3) are mildly thickened.
+There is mild to moderate aortic valve stenosis (area 1.2 cm2).
+No aortic regurgitation is seen. The mitral valve leaflets are
+mildly thickened. Physiologic mitral regurgitation is seen
+(within normal limits). [Due to acoustic shadowing, the severity
+of mitral regurgitation may be significantly UNDERestimated.]
+The tricuspid valve leaflets are mildly thickened. Moderate [2+]
+tricuspid regurgitation is seen. There is moderate pulmonary
+artery systolic hypertension. There is a small pericardial
+effusion. There are no echocardiographic signs of tamponade.
+
+2163-11-23 Pathology report
+1.  Lymph nodes, 4L, biopsy (A-C):
+Metastatic neuroendocrine neoplasm, most consistent with
+carcinoid tumor, in two of ten lymph nodes/lymph node fragments.
+2.  Lymph nodes, 7, biopsy (D):
+Metastatic neuroendocrine neoplasm, most consistent with
+carcinoid tumor, in three of four lymph nodes/lymph node
+fragments. See note.
+3. Lymph nodes, level 7, biopsy (E):
+Metastatic neuroendocrine neoplasm, most consistent with
+carcinoid tumor, in one of two lymph nodes/lymph node fragments.
+Note:
+Immunohistochemical stains show the tumor cells are diffusely
+positive for synaptophysin and chromogranin and are negative for
+CK 7 and TTF-1.  Rare tumor cells are positive for CK20.
+Despite the negative TTF-1, the tumor is compatible with a lung
+primary.  Clinical correlation recommended.
+
+FLOW CYTOMETRY 11-23:
+FLOW CYTOMETRY IMMUNOPHENOTYPING:
+
+The following tests (antibodies) were performed:  HLA-DR, FMC-7,
+Kappa, Lambda and CD antigens:  2,3,5,7,19,20,23, and 45.
+
+
+
+RESULTS:
+
+Three color gating is performed (light scatter vs. CD45) to
+optimize lymphocyte yield.  B cells comprise 34% of
+lymphoid-gated events, are polyclonal, and do not express
+aberrant antigens.  T cells comprise 50% of lymphoid gated
+events, and express mature lineage antigens.
+
+INTERPRETATION:
+Non-specific T cell dominant lymphoid profile; diagnostic
+immunophenotypic features of involvement by lymphoma are not
+seen in specimen.  Correlation with clinical findings and
+morphology (see S08-85352) is recommended.  Flow cytometry
+immunophenotyping may not detect all lymphomas due to
+topography, sampling or artifacts of sample preparation.
+
+11-23 Bronchial Washings:
+ Bronchial washing, left upper lobe:
+
+  NEGATIVE FOR MALIGNANT CELLS.
+
+  Reactive bronchial epithelial cells and alveolar
+  macrophages.
+
+ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL)
+was
+  reviewed and shows alveolar macrophages. No evidence of
+  malignancy.
+
+11-23 CXR:
+FINDINGS: No pneumothorax. There is complete opacification of
+the left lung, which is indicating collapse in the left upper
+lung, likely due to mucus plug. There is overlapping
+opacification, which was seen on the previous film, in the left
+lower lung which might be postoperative, inflammatory, or
+malignant and further evaluation is needed.
+
+There is a small right pleural effusion, unchanged. There is no
+consolidation in the right lung. The right jugular line was
+removed.
+
+2163-11-23 CXR Post-Bronch:
+
+FINDINGS: As compared to the previous examination, the left lung
+is slightly better aerated. There is no evidence of left-sided
+pneumothorax. In the right lung, in the middle lobe, some subtle
+areas of atelectasis are seen. No evidence of larger pleural
+effusions.
+
+2163-11-24 CXR:
+PORTABLE CHEST RADIOGRAPH: Compared to recent studies of
+2163-11-23, there is improved aeration of the left upper lung,
+without evidence of new
+pneumothorax. There persists opacification of the left perihilar
+and left
+lower lung, likely representing combination of pleural effusion
+and
+atelectasis, although underlying consolidation cannot be
+excluded. There is also improved aeration of the right lung
+although small right pleural effusion persists.
+
+2163-11-25 CXR:
+REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy.
+
+Since yesterday, diffuse opacification of the left lung is
+overall unchanged, mostly in the perihilar and left lower lung
+region, likely a combination of left pleural effusion and
+atelectasis, possibly consolidation. Small right pleural
+effusion is unchanged. The right lung is otherwise normal. There
+is no other change.
+
+2163-11-25 CT Scan Chest:
+
+IMPRESSIONS:
+1. Subcutaneous gas consistent with recent mediastinoscopy. A
+small left
+lower paratracheal collection containing fluid and gas could
+represent post- procedural changes. Correlation with recent
+procedure and clinical symptoms recommended. Multiple
+mediastinal lymph nodes are noted. Larger soft tissue density in
+the subcarinal region could represent lymphadenopathy or in the
+right clinical context could also represent a hematoma.
+Comparison with prior study if available could help
+differentiate between the two.
+
+2. Status post left lower lobectomy with fibrotic changes and
+atelectasis
+noted in the left lung. Fluid collection with thick enhancing
+rind in the
+left posterior sulcus is chronic and organized.
+
+3. Nodule in the anterior left lung could represent rounded
+atelectasis,
+though in atypical location. Recurrent tumor cannot be excluded.
+
+
+4. Moderate right dependent pleural effusion with associated
+dependent
+atelectasis of the left lower lobe.
+
+5. Left adrenal mass. Dedicated imaging of the adrenal glands
+recommended
+for further evaluation. There is also suggestion of
+lymphadenopathy in the
+retroperitoneum that is incompletely imaged. Small ascites noted
+along the
+dome of the liver.
+
+EKG 2163-11-27:
+Normal sinus rhythm. Poor R wave progression, possibly related
+to lead
+placement. No other abnormality. No previous tracing available
+for
+comparison.
+  Intervals Axes
+Rate PR QRS QT/QTc P QRS T
+72 0 88 912-120-18471
+
+OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of 2163-11-29
+Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE
+NEOPLASM
+Prelim findings c/w metastatic carcinoid, full report pending.
+
+2163-11-21 07:32PM   GLUCOSE-130* UREA N-119* CREAT-2.2*
+SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16
+2163-11-21 07:32PM   estGFR-Using this
+2163-11-21 07:32PM   CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4
+2163-11-21 07:32PM URINE  HOURS-RANDOM UREA N-828 CREAT-45
+SODIUM-LESS THAN
+2163-11-21 07:32PM URINE  OSMOLAL-427
+2163-11-21 07:32PM   WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4*
+MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1
+2163-11-21 07:32PM   NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0
+BASOS-0
+2163-11-21 07:32PM   PLT COUNT-389
+2163-11-21 07:32PM   PT-33.9* PTT-43.6* INR(PT)-3.6*
+2163-11-21 07:32PM URINE  COLOR-Yellow APPEAR-Clear SP Gruwell-1.013
+2163-11-21 07:32PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
+GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
+
+Other labs:
+Hematology
+  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
+2163-12-1 05:45AM    5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6
+288
+2163-11-30 08:05AM    5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7
+277
+2163-11-29 06:45AM    5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1
+280
+2163-11-28 07:00AM    6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4
+242
+2163-11-27 07:25AM    9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5
+247
+
+  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
+2163-12-1 05:45AM    96 18 1.0 147* 4.0 105 37* 9
+2163-11-30 08:05AM    81 20 0.9 145 4.0 108 34* 7*
+2163-11-29 06:45AM    77 22* 0.9 1441 4.0 106 36* 6*
+2163-11-28 07:00AM    79 27* 1.0 144 4.1 105 32 11
+2163-11-27 07:25AM    95 30* 1.0 143 4.0 106 33* 8
+2163-11-26 07:00AM    103 37* 0.9 143 4.2 107 33* 7*
+2163-11-25 03:37PM    104 43* 1.0 147* 4.4 110* 33* 8
+2163-11-25 02:07AM    168* 60* 1.0 146* 4.3 110* 31 9
+2163-11-24 04:25AM    92 87* 1.2 150* 4.2 113* 31 10
+2163-11-23 07:05AM    97 115* 1.7* 147* 4.5 108 31 13
+2163-11-22 02:52PM      126* 2.0*
+2163-11-22 05:34AM    122* 125* 2.1* 143 4.5 104 28 16
+DIG ADDED 9:08AM
+2163-11-21 07:32PM    130* 119* 2.2* 141 3.8 100 29 16
+
+2163-11-27 07:25AM   BNP 7554*1
+
+
+  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
+
+2163-12-1 05:45AM          8.9 3.2 2.2
+2163-11-30 08:05AM          9.0 3.4 2.3
+2163-11-29 06:45AM          9.0 2.8 2.3
+2163-11-28 07:00AM          8.6 2.7 2.2
+
+HEMATOLOGIC calTIBC Ferritn TRF
+2163-11-22 05:34AM    153* 270 118*
+DIG ADDED 9:08AM
+PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
+2163-11-22 05:34AM    NO SPECIFI1 1700-410-4771 NO MONOCLO2
+
+  DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
+Bilirub Urobiln pH Leuks
+2163-11-22 01:50PM    NEG NEG NEG NEG NEG NEG NEG 5.0 NEG
+Source: Catheter
+MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
+RenalEp
+2163-11-22 01:50PM    3* 2 FEW NONE <1 <1
+Source: Catheter
+URINE CASTS CastHy
+2163-11-22 01:50PM    9*
+Source: Catheter
+
+OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other
+
+2163-11-24 08:13AM    01 01 71* 8* 6* 15* 02
+BRONCHIAL LAVAGE
+
+
+2163-11-25 3:37 pm SPUTUM      Source: Expectorated.
+
+                            **FINAL REPORT 2163-11-27**
+
+   GRAM STAIN (Final 2163-11-27):
+      <10 PMNs and >10 epithelial cells/100X field.
+      Gram stain indicates extensive contamination with upper
+respiratory
+      secretions. Bacterial culture results are invalid.
+      PLEASE SUBMIT ANOTHER SPECIMEN.
+
+2163-11-24 8:13 am BRONCHOALVEOLAR LAVAGE      BRONCHIAL LAVAGE.
+
+                            **FINAL REPORT 2163-11-26**
+
+   GRAM STAIN (Final 2163-11-24):
+      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
+      NO MICROORGANISMS SEEN.
+
+   RESPIRATORY CULTURE (Final 2163-11-26):    NO GROWTH, <1000
+CFU/ml.
+
+2163-11-23 7:10 pm TISSUE     Site: LYMPH NODE
+
+   GRAM STAIN (Final 2163-11-23):
+      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
+LEUKOCYTES.
+      NO MICROORGANISMS SEEN.
+
+   TISSUE (Final 2163-11-26):    NO GROWTH.
+
+   ANAEROBIC CULTURE (Final 2163-11-29):    NO GROWTH.
+
+   ACID FAST SMEAR (Final 2163-11-24):
+      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
+
+   ACID FAST CULTURE (Preliminary):
+
+   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
+
+   POTASSIUM HYDROXIDE PREPARATION (Final 2163-11-24):
+      NO FUNGAL ELEMENTS SEEN.
+
+   LEGIONELLA CULTURE (Final 2163-11-30):    NO LEGIONELLA
+ISOLATED.
+
+   Immunoflourescent test for Pneumocystis jirovecii (carinii)
+(Final
+      2163-11-24):    NEGATIVE for Pneumocystis jirovecii
+(carinii)..
+
+
+Brief Hospital Course:
+76M initially admitted  to Davis Hospital hospital for CHF
+exacerbation, and then transferred ICU-to-ICU for workup of
+chronic mediastinal LAD.  Thoracic Surgery had been contactTammy
+and was interested in seeing the patient and deemed that he
+would be most appropriate for MICU given his ongoing ARF.  While
+in the ICU his renal function improved with gentle intravascular
+hydration. Echo was performed which revealed severe diastolic
+dysfunction with ejection fraction of >70%.  His digoxin was
+therefore discontinued.  He was discharged to the floor after
+~24 hours of observation.
+
+While on the medical service, the patient was brought to the OR
+on 2163-11-23 for Flexible bronchoscopy with bronchoalveolar
+lavage  of the left upper lobe, cervical mediastinoscopy and
+bronchoscopy.  On post-op CXR there was noticeable whiteout of
+the left lung field and the patient was kept in the PACU for
+observation.  He was treated with Chest PT, IS and suctioning
+for the thought of possible mucus plugging.  As per
+documentation, the patient was doing well until the morning when
+he had increasing oxygen requirements and more labored
+breathing.  At 8am on 2163-11-24 the patient underwent
+unremarkable bronchoscopy by IP.  Patient continued to have a
+significant oxygen requirement, satting 93% on 40% facemask,
+thus was transferred to the ICU for monitoring.
+
+In ICU on 11-25, patient underwent upper airway suctioning,
+along with albuterol, ipratropium, and mucinex treatment. He
+utilized incentive spirometry as well. Serial chest x-rays
+showed eventual clearing of his left lung. His oxygen saturation
+improved to 100% on 4L.  He underwent a chest CT which showed a
+large right pleural effusion and left airspace disease possibly
+consistent with pneumonia.  he continued to produce increasing
+amounts of airway mucous.  Though he did not spike a fever or
+develop a leukocytosis, he was started on empiric coverage for
+hospital acquired pneumonia with vancomycin and zosyn.  This was
+continued for a total of 4 days, and then discontinued.  His
+respiratory status continued to improve, and he was weaned down
+to 2L NC O2, and often maintained O2 sats > 94% on room air at
+rest.
+
+He was transferred from the ICU to the medicine floor on 11-25,
+where the below issues were addressed:
+
+Hypoxia: Thought to be due to mucus plugging in setting of
+procedure. Given the acuity of both the change and the reversal
+it is likely that he experienced lung collapse and then
+reaeration of expectorating mucus. Received 4 days of vanc/zosyn
+for presumed HAP coverage in setting of hypoxia and increased
+sputum production, this was d/c'd 11-28 with no additional fevers
+and decreasing sputum.  He was continued on ipratropium nebs,
+mucomyst nebs, guaifenesin, incentive spirometry.  During his
+stay, his oxygen requirement was weaned, now requiring 2L NC
+only intermittently. Will continue albuterol and ipratropium
+nebs on a prn basis.
+.
+Hypernatremia: Na as high as 150, did decrease with IVF but
+still mildly elevated on transfer to floor.  Improved to 147
+with D5W.  IV hydration stopped at this time and POs encouraged
+given risk of CHF. Free water deficit estimated at 2.3L on
+transfer to floor.  Na remained stable in range of 143-147 when
+taking more PO fluid.  Recommend continued intermittent
+monitoring.
+
+LAD: s/p mediastinoscopy.
+His mediastinal lymph node biopsy results were consistent with
+carcinoid.  The hematology/oncology service was consulted, and
+they recommended getting an octreotide scan, the preliminary
+read showed metastatic carcinoid.  These results were discussed
+with the patient and his outpatient oncologist. The patient
+requested to be followed by his oncologist in Lewis Memorial Hospital.
+.
+diastolic Congestive Heart Failure: ECHO with EF of 75%, has
+severe dCHF. Cards consulted while in ICU.  Digoxin was
+discontinued in setting of diastolic CHF.  Cardiology
+recommended using either BB or verapamil to control HR, goal to
+have <80. HR was well controlled without meds on transfer from
+ICU.  Added Metoprolol 12.5 mg Meredith Medical Center on 11-26, though this was
+d/c'd 11-27 for episodes of bradycardia to 30s. Added 12.5
+Metoprolol SR 11-28, which he has tolerated well.  Also added
+Candesartan at low-dose (4mg, home dose 16 mg) given h/o
+diastolic CHF and goal of reducing afterload.  This can be
+titrated up as his blood pressure allows.  He did have some
+increased edema during his stay on the medical floor, and was
+given TEDs stockings and encouraged to ambulate.  He also
+received 40 mg IV lasix x 1 2163-11-28, and an additional dose of
+40 mg po on 11-30 and 40mg IV on 12-1.  The long-term goal
+remains to minimize diuretics, but use extreme caution with
+fluids as pt is exquisitely volume sensitive due to severity of
+dCHF.  Discharged with instructions to continue home lasix (40
+mg) for 3 days with monitoring of daily weights and chemistries,
+this may need to be reassessed and monitored.
+.
+RHYTHM: He has chronic afib.  His heparin was held after
+surgery.  He was restarted on coumadin 1.25 mg daily on 11-26.
+His INR rose to the therapeutic range, and was 2.5 on discharge.
+ Recommend intermittent monitoring to tritrate necessary dosing
+regimen.
+.
+ARF: Improved with hydration. Renal signed off prior to transfer
+to floor.  Diuresis minimized on the floor, received 40 mg IV
+lasix and 40mg PO lasix on two occasions with good diuresis, pt
+maintained blood pressures.  The goal continues to be to
+minimize diuresis to prevent excessive preload reduction.
+.
+CAD: He was continued on his statin, held ASA due to h/o GI
+bleed
+
+
+
+
+
+Medications on Admission:
+PPI
+Lipitor 10
+Atacand 16 (confirmed with spouse)
+Digoxin 0.125 mg qd
+Aldactone 25 qd
+Lasix 40 qd
+Allopurinol 100 mg qd
+Verapamil 180 qd
+Coumadin 2.5 (MWF); 1.25 (TTSS)
+Flomax 0.5
+
+
+Discharge Medications:
+1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
+Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
+2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily).
+3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
+(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
+4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
+(Daily).
+5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily ().
+6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
+Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
+7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
+day) as needed.
+8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
+times a day).
+9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
+Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
+needed.
+10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
+Inhalation Q6H (every 6 hours) as needed.
+11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3
+days.
+
+
+Discharge Disposition:
+Extended Care
+
+Facility:
+Lianes Medical Center - Thundera
+
+Discharge Diagnosis:
+Primary:
+Mediastinal Lymphadenopathy
+Metastatic Carcinoid
+Acute renal failure
+
+Secondary:
+chronic diastolic congestive heart failure
+anemia
+atrial fibrillation
+chronic renal insufficiency
+
+
+Discharge Condition:
+fair, tolerating PO, afebrile, VS wnl, O2 95-100% on
+supplemental O2 2L Tomblin Hospital transfer to chair with assist
+
+
+Discharge Instructions:
+You were admitted to the hospital with mediastinal
+lymphadenopathy.  You had a mediastinoscopy and bronchcoscopy.
+The pathology reports showed this was consistent with carcinoid.
+ You were seen by the oncologists, who recommended an Octreotide
+scan; you indicated you would like to follow up with your
+outpatient oncologist.
+
+You were also noted to have an exacerbation of your heart
+failure.  You were seen by the cardiologists, who recommended
+you stop your digoxin.  You were given diuretics to remove
+fluid.  You also had acute renal failure, which resolved during
+your stay.
+.
+A CT scan showed a mass on your left adrenal gland, this should
+be worked up as an outpatient, you should talk with your primary
+care doctor about further evaluation.
+.
+The following changes were made to your medications:
+Your digoxin, verapamil and aldactone were stopped
+Your atacand dose was decreased to 4 mg
+You were started on metoprolol
+You were started on docusate, senna, and bisacodyl as needed for
+constipation and albuterol and ipratropium nebs as needed for
+SOB/wheezing
+Your allopurinol and flomax were held, these can be restarted
+during your rehab stay
+Your coumadin was decreased to 1.25 mg daily, this can be
+adjusted based on your INR
+.
+Please call your doctor or return to the ED for:
+- fevers/chills
+- shortness or breath or chest pain
+- increasing sputum production
+- weight gain > 3 lbs
+- any other new or concerning symptoms
+
+Followup Instructions:
+Follow up with your primary care provider, Cooper. Audry Hall
+(576-277-8956, within 1 week of leaving rehab.  On a CT scan,
+you were noted to have a mass on your left adrenal gland, and
+they recommended dedicated CT or MRI for better
+characterization.  Dr. Mora should help you this setting this
+up.
+
+Follow up with your cardiologist  Dr. Morales Carol 118-669-6208,
+fax 186-417-7342 within the next 2-3 weeks for reevaluation and
+adjustment of heart failure meds as needed.
+
+Oncology Dr. Gean 989-690-8790.  You have an appointment on
+12-13 at 1:20 PM, call if you need to reschedule or be
+seen sooner.
+
+
+
+"
+"Admission Date:  2139-2-27     Discharge Date:  2139-3-10
+
+
+Service:
+
+ADMITTING DIAGNOSIS:  Barrett's esophagus with high grade
+dysplasia.
+
+DISCHARGE DIAGNOSES:
+1.  Barrett's esophagus with high grade dysplasia.
+2.  Status post trans-hiatal esophagectomy.
+3.  Aspiration.
+4.  Myocardial infarction.
+5.  Cardiogenic shock.
+6.  Anoxic encephalopathy.
+7.  Death.
+
+HISTORY OF PRESENT ILLNESS:   The patient is an 84 year old
+male who had a long standing history of gastroesophageal
+reflux disease and Barrett's esophagus and had high grade
+dysplasia diagnosed on recent endoscopy.  The patient elected
+to have an esophagectomy performed.
+
+PAST MEDICAL HISTORY:
+1.  Hypertension.
+2.  Question renal insufficiency.
+3.  Gastroesophageal reflux disease.
+
+MEDICATIONS:
+1.  Norvasc.
+2.  Prilosec.
+3.  Carafate.
+
+PHYSICAL EXAMINATION:   On admission, the patient is an
+elderly man in no acute distress.  Vital signs are stable.
+Afebrile.  Chest is clear to auscultation bilaterally.
+Cardiovascular is regular rate and rhythm without murmur, rub
+or gallop.  Abdomen is soft, nontender, nondistended without
+masses or organomegaly.  Extremities are warm, not cyanotic
+and not edematous times four.  Neurological is grossly
+intact.
+
+HOSPITAL COURSE:   The patient was taken to the Operating
+Room on 2139-2-27, where he underwent transhiatal
+esophagectomy without significant complication.  In the
+postoperative course, he was initially admitted under the
+Intensive Care Unit care and kept in the Post Anesthesia Care
+Unit overnight.  The patient was seen to have a low urine
+output and both metabolic and respiratory acidosis and was
+given approximately 8.5 liters of Crystalloid in the
+perioperative period, including OR.
+
+The patient was briefly agitated in the Post Anesthesia Care
+Unit and discontinued his nasogastric tube.  On postoperative
+day number one, the patient was doing well with a fairly
+normalized blood gas of 7.35/43/94/25/minus 1 and was
+transferred to the floor.
+
+On postoperative day two, the patient was seen to have a
+baseline oxygen requirement of 70% face mask in the morning
+but was saturating well and otherwise seemed to be doing
+relatively well.
+
+The patient had a white count of 22.1 which prompted a chest
+x-ray showing bilateral pleural effusion and patchy bibasilar
+atelectasis but no focal infiltrates.  Over the course of the
+day, the patient had deteriorating in his respiratory status
+and became increasingly tachypneic with wheezing and coarse
+breath sounds.
+
+An EKG was performed which showed atrial fibrillation but no
+ischemic changes.  A baseline arterial blood gas was obtained
+at that point which was 7.37/47/86/28/zero, again on 70% face
+mask.
+
+Intravenous fluids were then stopped and the patient was
+begun on 20 mg of intravenous Lasix and albuterol nebulizers.
+The patient was transferred to another floor for Telemetry
+purposes and cycled for myocardial infarction.  His
+respiratory status during transfer seemed somewhat improved.
+Upon arrival to the other floor, the patient stopped
+respiring briefly and went bradycardic.  Upon stimulation, he
+was tachycardic to the 110s with a blood pressure 130/70.
+
+Immediately subsequent to that the patient went pulseless and
+into respiratory and cardiac arrest and was down for
+approximately two to three minutes.  CPR was begun and the
+patient intubated and 15 to 20 cc. of brownish fluid was
+suctioned from the endotracheal tube post intubation.
+
+The patient regained pulse and cardiac activity and was
+transferred to the Intensive Care Unit.
+
+Cardiac consultation at that time recommended aspirin,
+cycling enzymes and agreed with probable aspiration event.
+They suggested a heparin drip but not is surgically
+contraindicated.  A heparin drip was not started.  The
+patient ruled in for myocardial infarction with a troponin of
+26.5.
+
+In the patient's Intensive Care Unit stay, he was supported
+with a dopamine drip and diuresed for fluid overload.
+Pressors were weaned off on postoperative day number eight.
+Respiratory function was supported throughout his Intensive
+Care Unit course appropriately with mechanical ventilation.
+
+The patient was noted to be unresponsive after the aspiration
+event, with some slow return of responsiveness over the next
+several days, but no purposeful movement.  To evaluate
+possible neurologic injury, a CT scan was obtained after the
+patient was felt to be stable enough to be transferred.
+
+On postoperative day six, the CT scan showed no acute
+intracranial event but was consistent with chronic
+microvascular infarction.  EEG was also obtained which
+revealed diffuse widespread encephalopathy.  There was a
+question of possible seizure activity involving the left
+upper extremity and phenytoin was begun empirically.
+
+A repeat EEG was obtained on postoperative day number 10 and
+again showed moderately severe diffuse encephalopathy with no
+seizure focus.
+
+A Neurology consultation was obtained and assessed the
+patient to have minimal chance for a meaningful recovery.
+
+In accordance with the patient's living will, the family's
+wishes and discussion with the surgical attending, the
+patient was made comfort measures only and expired on
+postoperative day number 11.
+
+
+                          Joshua Guttmann, M.D.  P39287153
+
+Dictated By:Branch
+
+MEDQUIST36
+
+D:  2139-3-24  10:08
+T:  2139-3-28  16:18
+JOB#:  Job Number 48824
+"
+"Admission Date:                   Discharge Date:
+
+Date of Birth:                    Sex:  M
+
+Service:  UROLOGY
+HISTORY OF PRESENT ILLNESS:  Mr. Stephen is a 53-year-old
+gentleman who presented on 2121-6-28 for cystectomy and
+neobladder diversion.  He had grade 3 of 3 TCC.
+
+PAST MEDICAL HISTORY:
+2.  Myocardial infarction in '09
+3.  Hypertension
+4.  Left internal capsule cerebrovascular accident in '18
+5.  Hypothyroidism
+6.  Gastroesophageal reflux disease
+7.  Hypercholesterolemia
+8.  Depression
+PAST SURGICAL HISTORY:
+1.  TURBT's in '13 and '15
+
+ALLERGIES:  He has no known drug allergies.
+
+HOME MEDICATIONS:
+1.  Aspirin 250 mg q.d. which was held
+2.  Metoprolol 25 mg b.i.d.
+3.  Levoxyl 300 mcg once a day
+4.  Paxil 40 mg once a day
+5.  Lipitor 20 once a day
+
+ADMISSION LABS:  CBC of 9.3, 43.6, 252.  Chem-7 of 135, 4.4,
+97, 23, 16, 0.8, 252.  PT 12.8, PTT 24.4, INR 1.1.  Liver
+enzymes:  ALT 23, AST 18, alkaline phosphatase 101, albumin
+3.8, total protein 7.4.
+
+IMAGING:  Preoperative electrocardiogram showed left atrial
+abnormalities with Q-waves in 2, 4, AVF, V5, V6.  Thallium
+stress test done preoperatively showed normal heart rate,
+normal blood pressure, normal respirations, no acute
+electrocardiogram changes, some portal V-function from an old
+infarction prior myocardial infarction, however it was clear
+for the operation.  His chest films revealed no acute
+cardiopulmonary process.
+
+The inital surgery resulted in creation of a neobladder from
+ileum. Postoperatively, the patient remained intubated with a
+septic picture that deteriorated, requiring pressor agents.
+ The patient returned to the Operating Room on
+2121-7-8 for an exploratory laparotomy and excision of an
+infarcted neobladder and resection of a nonviable segment of
+small bowel x2, creation of a jejunal conduit.  His postop
+course was equally stormy with spiking fevers, renal failure,
+and BP instability
+A third surgical exploration was necessary on 7-26.  At this time,
+the patient
+More ischemic bowel was removed where perforations had occurred
+resulting in peritonitis.  The jejunal loop was excised and the
+right ureter ligated. A left cutaneous ureterostomy was created.
+Postop he had bilateral nephrostomies inserted and continued to
+have an extended stormy ICU course.  A tracheostomy was
+necessary because of hi need for prolonged ventilator support.
+He also developed extensive DVT requiring anticoagulation.
+Bowel function gradually returned allowing for tube feedings.
+Multiple courses of antibiotic therapy were given during his
+hospital stay.
+
+NEUROLOGICALLY:  By system, neurologically the patient is
+status post a left internal capsule infarct with residual
+right sided weakness.  His history of depression leaves on
+Paxil and he was started on such.  Radiologically, the
+patient had a CT done of the head done during his admission.
+Showed a stable appearance, considering no definitive
+evidence of any type of abscess.  Neurologically, the patient
+is being discharged home and is stable.  He is alert, however
+he is unable to move secondary to his wasting and being in
+bed for so long without assistance.  The patient is able to
+get out of bed to chair.  Neurologically, the patient has no
+acute issues upon discharge.
+
+CARDIOVASCULAR:  The patient is status post myocardial
+infarction in 2109 and he did not have a myocardial
+infarction during the course of his stay in-house at the
+hospital and he was ruled out by enzymes with no acute
+electrocardiogram changes.  The patient has no acute
+cardiovascular issues.  The patient is not on clonidine, nor
+is he on Lopressor currently and his pressure is tolerating,
+basically being on nothing.  The patient had been on pressors
+immediately because of sepsis which was weaned off slowly
+during the course of his stay.  He has not been on pressors
+for the previous month.
+
+RESPIRATORY:  The patient had poor respiratory failure and
+required full respiratory support.  He is postoperative his
+three operations and has been slowly weaned down to a
+pressure support of 40 with a CPAP pressure support with 405
+FIO2 with a PEEP of 5 and a pressure support of 5 with tidal
+volumes ranging from 550 to 650.   The patient
+was also bronched on 8-22 and mucous plugs were removed from
+the patient.  A CT done on this patient in the last two weeks
+in the middle of January showed that he had no acute
+pulmonary process with possible left lower lobe pneumonia.
+At that point, he had also been on antibiotics with this
+course.  Upon discharge, the patient has no acute pulmonary
+process and his lungs are sounding remarkably clearer.
+
+GASTROINTESTINAL:  The patient is not able to eat on his own
+and has a left Dobbhoff tube and is suffering from short--gut
+syndrome requiring B12 injections.  The patient is currently
+tolerating his tube feeds of Impact at goal rate of 90 cc an
+hour and is having some stool output.  Clostridium difficile
+sent on the patient recently as of 9-15 came back negative.
+The patient is receiving all his feeds through tube feeds and
+is not a candidate for a PEG given his previous abdominal
+surgery.  The patient's other gastrointestinal issues are
+obviously evolving around the reception as previously stated
+of massive portions of his small bowel, as well as the large
+bowel and appendix.  Upon discharge, there are no acute
+discharge issues for this patient.
+
+GENITOURINARY:  The pathology report from the original
+surgery showed a high grade invasive TCC involving the
+bladder neck, prostate, urethral margin and regional
+nodes.  His right ureter is tied off secondary to
+the leak and he has a right nephrostomy tube which was
+changed on 9-16 as well as his left nephrostomy tube.  His
+ureterostomy tube on the left side was changed on 9-18.  All
+this was done in response to his febrile episode he had which
+will be outlined later which was felt to be urosepsis.  On
+discharge, it was found that his nephrostomies were positive
+for yeast, most likely colonized.  The patient was not on any
+type of antimicrobial for that.  The patient has been showing
+yeast growing from the left side nephrostomy and
+ureterostomies almost to his Intensive Care Unit stay, but no
+evidence of acutely febrile as a result most likely due to
+colonization.  The patient has a left nephrostomy tube in
+addition to the ureterostomy of the left side and does not
+have a Foley inserted into his neobladder obviously because
+of drainage from that point of view.  Upon discharge from a
+urological standpoint, the patient is stable.  His tubes are
+draining clear urine and there is no blood present.  Some
+blood may be noted in the urine with positional changes on
+the patient and that is completely normal as long as it is
+consistent with old blood and no massive bleeds.
+
+EXTREMITIES:  The patient was found to have a lower extremity
+deep venous thrombosis on 8-3, as well as 8-8 which found
+upper extremity bilateral deep venous thromboses.  The
+patient basically had deep venous thromboses x4 and was
+started on a heparin drip continuously to resolve his deep
+venous thromboses and heparin drip was continued until
+Coumadin was started in the last two weeks of January prior
+to his discharge.  An ultrasound of the upper extremities
+done on Mr. Stephen on 9-12, showed that he resolved his
+upper extremity clots completely with the exception of some
+small residual clot at the left and right IJ.  The patient is
+being discharged on Coumadin with the hope of achieving an
+INR of approximately 2 to 2.5.  The most recent INR was 1.3,
+came back on 9-18 and the patient continued to receive
+Coumadin until he reaches his goal without any heparin.  In
+addition, the patient's hematocrit has remained stable,
+however.
+
+HEME:  The patient has been on Coumadin.  His hematocrit has
+remained stable as of late and his last blood transfusion was
+on 7-12.  Since then, his hematocrit has remained stable at
+around 29 to 28 with no acute signs of bleeding.  As far as
+his renal function, the patient has been increasing sodium
+and has been given free water to resolve that.  His
+hematocrit is stable and his white cell count on 9-18 was
+8.0.
+
+INFECTIOUS DISEASE:  The patient was febrile postoperative
+and several cultures were sent out.  Regarding his blood
+cultures, from 7-8 to the middle of January, he did not
+grow anything out.  He was on triple antibiotics which were
+actually discontinued on 2121-8-29.  He failed to grow
+anything however fluconazole was continued until 9-2 to rule
+out any other type of infection and to make sure that there
+was no acute yeast systemic process going on even though he
+had colonized his tubes.  The patient became febrile again on
+9-8 unfortunately with a T-max of 104.4??????.  The patient was
+started immediately on vancomycin, Zosyn and fluconazole
+until cultures came back.  Blood cultures and catheter
+cultures came back revealing that the patient had been
+infected and was handling what was later decided was probably
+urosepsis for Klebsiella.  Based on this, the patient resumed
+a 10 day treatment cycle of Levaquin based on infectious
+disease's recommendation and the other antibiotics were
+stopped.  This is actually day 8 of 10 of his levofloxacin
+course and as of 2121-9-19 the patient will be receiving two
+more days of Levaquin.
+
+The patient upon discharge is afebrile and his surveillance
+blood cultures have come back negative even though his
+nephrostomy tubes which were changed showed some fungal
+colonization growth.  His blood has remained negative for any
+type of infection.  During his stay, other cultures sent off
+included blood flowing through his catheter lines which were
+negative except for that one change which was required on
+9-8 after he became febrile.  His left subclavian has
+changed.  Today, on 9-19, he has a right sided subclavian of
+the left sided one which was considered a possible source of
+infection.  His lines are not likely the source of the
+infection.  It is hoped that he will get a PICC line before
+he is discharged to rehabilitation today and his central line
+will be taken out.
+
+MICROBIOLOGY:  A spinal tap was also done and no consequence
+of that resulted.  No significant findings.
+
+Today, the patient is being discharged and he is on the
+following medications:
+1.  Glutamine 5 mg p.o. tube feeds to prevent excessive
+stool, secondary to short-gut.
+2.  NPH 8 units subcutaneous b.i.d.
+3.  Thyroxine 200 mcg p.o. q.d.
+4.  Vitamin C p.o. per the nasogastric tube every day.
+5.  Insulin sliding scale 2, 4, 6, 8 which is not being used
+much.
+6.  Paxil 20 mg nasogastric tube q.d.
+7.  Levofloxacin 500 mg intravenous to be continued for
+another two days hopefully.
+8.  Tincture of iodine 10 drops to every 500 cc of tube
+feeds.
+
+He received 2.5 mg of Coumadin last night.  He has not
+received any recent Dilaudid or albuterol nebulizer
+treatment.  He is receiving KCL 40 mg intravenous prn for low
+potassium of less than 4, magnesium of 2 gm intravenous prn
+for less than 2.0 magnesium levels, last dose on 9-18, as was the last dose of potassium.  The patient has not
+been requiring any Ativan or Dilaudid or sedation as of
+recently.  He was on Epogen for a hematocrit which has now
+been stabilized, so it is no longer as issue.  It was felt
+that the patient was in early on acute renal failure which
+turned out to be a leak and the patient is not on renal
+failure, no requiring any Epogen.  On this date, 9-19, Mr.
+Stephen is basically receiving in addition to just the
+glutamine 5 mg tube feeds, Synthroid which are outlined and
+he is also getting Protonix 40 mg intravenous q.d. for
+gastrointestinal prophylaxis, as well as Coumadin to keep an
+INR of 2 to 2.4 for prophylaxis.
+
+It is our hope that Mr. Schrack, despite his advanced
+cancer and multiple surgeries, will be rehabilitated and able
+to resume assemblance of his functional life.  We hope that
+he continues receiving chest PT, that he is respiratorily
+stable with no acute issues at this time.  We also hope that
+he will eventually no longer require ventilatory support and
+a collar could be used on him as well as eventually assume
+breathing on room air.
+
+Final Diagnoses:
+1. Transitional Cell Ca of Bladder and Prostate, metstatic to
+regional nodes
+2. Multiple postoperative complications, including intestinal
+perforation with peritonitis, neobladder infarction, sepsis,
+vascular instability with hypotension, DVT, and renal
+insufficiency.
+3. Respiratory insufficiency
+4. s/p tracheostomy
+
+
+
+                            Michele Initial (NamePattern1)  Beaufort, MD  A79903668
+
+Dictated By:Leon
+MEDQUIST36
+
+D:  2121-9-19  09:01
+T:  2121-9-19  09:11
+JOB#:  Job Number 39316
+
+rp 2121-9-19
+"