diff --git "a/notes_small.csv" "b/notes_small.csv" --- "a/notes_small.csv" +++ "b/notes_small.csv" @@ -1,1403 +1,1312 @@ 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 +"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: 2188-1-12 Discharge Date: 2188-1-25 -D: 2175-1-9 12:42 -T: 2175-1-9 12:46 -JOB#: Job Number 52585 +Date of Birth: 2148-1-24 Sex: M + +Service: + +HISTORY OF PRESENT ILLNESS: The patient is a 39 year old +male who was an unrestrained driver involved in a rollover +motor vehicle accident. He was partially ejected from the +vehicle. He had a prolonged extrication time, approximately +30 minutes and was found unresponsive by paramedics at the +scene and intubated. The patient was transferred to an +outside medical facility where he had some left side crepitus +noted. He had a left chest tube placed for relief of this +pneumothorax. The patient, at that time, was noted to be +hypotensive and had a diagnostic peritoneal lavage performed +which was negative. The patient's chest x-ray at that time +showed a pneumothorax on the opposite side, on the right +side, for which another chest tube was placed. The patient +was packaged and prepared for transfer through Flores Memorial Hospital, however, upon wheeling the patient +away from that facility, he was found to be hypotensive +initially and then had an asystolic arrest. Two additional +bilateral chest tubes were placed with relief of bilateral +tension hemopneumothoraces with return of perfusing cardiac +rhythm. + +The patient was stabilized for transfer to Flores Memorial Hospital. Upon arrival in our Trauma Bay, +the patient was intubated, sedated, and paralyzed. The +patient had three chest tubes in place and was +hemodynamically stable. + +HOSPITAL COURSE: Trauma work-up at our facility revealed +bilateral pneumothoraces with minimal hemothoraces, +adequately drained by his chest tubes. However, persistent +air leaks were noted and it was identified that the patient'a +proximal ports of his chest tubes were out of the chest. +During the CT scan, he became hypotensive and these tubes had +to be emergently advanced with good result. + +The patient's trauma series revealed multiple rib fractures +and hemopneumothoraces as stated above. The patient had a +head CT scan which was negative and a CT scan of the cervical +spine which showed a tiny C5 avulsion fracture which was +non-displaced. CT scan of his chest revealed bilateral +pulmonary contusions, bilateral consolidation and a left +clavicular fracture. CT scan of his abdomen and pelvis +showed a minimal amount of free fluid consistent with his +diagnostic left clavicular fracture. CT scan of his abdomen +and pelvis showed a minimum amount of free fluid consistent +with his diagnostic peritoneal lavage. The patient also +noted to have multiple bilateral rib fractures. + +The patient's plain film also on a later read revealed +question of a left iliac Dr. Sanchez fracture which was +non-displaced. The patient also was noted by a consultation +by Orthopedic Surgeons to have a glenoid fracture in addition +to a humerus fracture. + +The patient was transferred to the Surgical Intensive Care +Unit where two fresh sterile chest tubes were placed and his +three other chest tubes were removed. He required +intermittent pressor support and aggressive fluid +resuscitation. Neurosurgery was consulted and determined +that this C5 fracture was nondisplaced, not requiring any +specific therapy, however, that the patient should be in a +hard collar for six weeks. + +The patient developed pulmonary infiltrate and some fevers +for which he was started on Ceftriaxone for some Gram +negative rods growing in his sputum. On hospital day four, +the patient was taken to the Operating Room by the Orthopedic +surgeons for open reduction and internal fixation of his +humeral fractures; the patient tolerated this procedure well +without any complications. + +Postoperatively, he was transferred back to the Surgical +Intensive Care Unit where he underwent a prolonged +ventilatory wean. The patient was extubated but noted to be +somewhat confused and initially combative. The patient was +thought to be withdrawing from alcohol and was started on +Ativan drips to control this. He progressed very well. +Mental status improved. He was transferred to the floor. On +the floor, he continued to do well with slowly improving +mental status. Psychiatry was consulted for care of this and +recommended a slow Ativan wean and slow Haldol wean. + +The patient's antibiotic course was completed. Follow-up +chest x-ray revealed resolution of his consolidations and the +patient's sputum became normal. He began working with +Physical Therapy and advanced to a regular diet which he +tolerated well and will be discharged to rehabilitation. + + + + DR.Tisdale,Adele 02-349 + +Dictated By:Weston +MEDQUIST36 + +D: 2188-1-24 08:52 +T: 2188-1-24 10:40 +JOB#: Job Number 38197 " -"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. +"Admission Date: 2126-3-21 Discharge Date: 2126-4-9 + +Date of Birth: 2074-3-9 Sex: M + +Service: SURGERY + +Allergies: +Patient recorded as having No Known Allergies to Drugs + +Attending:Jaime +Chief Complaint: +struck on head by large beam + +Major Surgical or Invasive Procedure: +anterior cervical fusion 3-21 +posterior cervical fusion 3-24 +Open trach, PEG 3-29 + +History of Present Illness: +52 year-old male who had a large metal Dr. Tran fall 8 inches onto +his head. No LOC but on arrival of EMS had no sensation or motor +function beloow nipples. In field SBP was in 90s started on +levophed. On arrival there was no sensation/motor function below +nipple line. The patient was intubated for agitation and started +on salumedrol drip. + + +Past Medical History: +healthy + +Social History: +married + +Family History: +non-contributory + +Physical Exam: +Awake and alert on arrival. +10 cm head laceration stapled in the trauma bay. Pupils are +equal and reactive. +Lungs are clear bilaterally. +Heart is regular. +Abdomen is soft, nontender, and nondistended. +Extremities are warm, perfused, but sensation to pin-prick is +absent over all extremities. there is no motor function over +any extremity. + + +Pertinent Results: +2126-3-21 09:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE +EPI-0-2 +2126-3-21 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR +GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG +2126-3-21 09:30AM URINE COLOR-Yellow APPEAR-Clear SP Cooper-1.026 +2126-3-21 09:30AM FIBRINOGE-251 +2126-3-21 09:30AM PT-12.7 PTT-21.4* INR(PT)-1.1 +2126-3-21 09:30AM PLT COUNT-187 +2126-3-21 09:30AM WBC-6.7 RBC-4.33* HGB-14.1 HCT-39.1* MCV-90 +MCH-32.7* MCHC-36.1* RDW-13.3 +2126-3-21 09:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG +cocaine-NEG amphetmn-NEG mthdone-NEG +2126-3-21 09:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG +bnzodzpn-NEG barbitrt-NEG tricyclic-NEG +2126-3-21 09:38AM GLUCOSE-167* LACTATE-1.4 NA+-140 K+-4.3 +CL--106 TCO2-23 +2126-3-21 12:51PM TYPE-ART PO2-225* PCO2-43 PH-7.29* TOTAL +CO2-22 BASE XS--5 +2126-3-21 01:11PM HCT-42.1 +2126-3-21 01:11PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.9 +2126-3-21 01:11PM GLUCOSE-214* UREA N-21* CREAT-0.9 SODIUM-137 +POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 + +Brief Hospital Course: +Mr. Adam was evaluated in the Trauma Bay and a spine +consult was obtained immediately. + +His injuries included: +C4-6,2-1 fractures, nonenhancing vertebral artery R C3-6, R 1st +rib, R clavicle, scalp lac, cervical epidural hematoma no +motor/senstn UEs or Esther +Zuniga/CTA Hd: no acute bleed +CT/CTA Csp: as above +CT Torso: as above + +The steroid protocol was initiated and continued for a total of +24 hours. He was brought to the operating room for an anterior +cervical fusion (3-21). The patient was stabilized and returned +to the OR for a posterior fusion (3-24). + +An IVC filter was placed by the Vascular surgery service. + +After the spine surgery team cleared the patient, an open +tracheostomy and percutaneous endoscopic gastrostomy tube were +performed (3-29). + +His postoperative course has been complicated by a postoperative +pneumonia. He was treated with a 7 day course of levofloxacin +for a pan sensitive enterobacter pneumonia (3-27). At present +he has MRSA (4-1, 4-2) growing from sputum and has been treated +now with 8 days of vancomycin. He also has been started on +pipercillin-tazobactam (4-8) for gram negative rods in his +sputum (4-2). + +Medications on Admission: +none + +Discharge Medications: +1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation +Q4H (every 4 hours) as needed. +2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal +HS (at bedtime) as needed. +3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 +times a day). +4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable +PO DAILY (Daily). +5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H +(every 4 to 6 hours) as needed for fever. +6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) +Injection TID (3 times a day). +7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID +(2 times a day). +8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal +HS (at bedtime) as needed. +9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO Q 24H +(Every 24 Hours). +10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY +(Daily). +11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML +Miscell. Q2H (every 2 hours) as needed. +13. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One +(1) PO DAILY (Daily). +14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H +(Every 3 to 4 Hours) as needed. +15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 +hours) as needed for mucous production. +16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as +needed. +17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID +(4 times a day) as needed. +18. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H +(every 6 hours). +19. Lorazepam 2 mg/mL Syringe Sig: 12-31 Injection Q2H PRN () as +needed for anxiety. +20. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln +Intravenous Q 8H (Every 8 Hours). +21. Ampicillin-Sulbactam 1-30 g Recon Soln Sig: Three (3) Recon +Soln Injection Q8H (every 8 hours). +22. Acetazolamide Sodium 500 mg Recon Soln Sig: One (1) Recon +Soln Injection Q6H (every 6 hours). + + +Discharge Disposition: +Extended Care + +Facility: +True Corporation + +Discharge Diagnosis: +C4-6, T2-3 fractures with quadraplegia + + +Discharge Condition: +stable + + +Discharge Instructions: +tracheostomy care +gastrostomy care + + + +" +"Admission Date: 2126-10-24 Discharge Date: 2126-10-30 + +Date of Birth: 2063-1-14 Sex: M + +Service: CSU + + +HISTORY OF PRESENT ILLNESS: This is a 63 year old gentleman +who has a prior history of myocardial infarction in 2122-2-17 who underwent stent to his left anterior descending and +right coronary artery at the time with subsequent multiple +episodes of instant restenosis, requiring brachytherapy. The +patient underwent a routine stress test, which showed +reversible anterior ischemia and was referred to Shaw Medical Center for cardiac catheterization. + +PAST MEDICAL HISTORY: Hypercholesterolemia. Status post +myocardial infarction. Status post multiple PCI. +Hypertension. Status post removal of colonic polyps. Status +post appendectomy. Status post removal of lipoma. Status +post removal of precancerous lesion from his back. + +ALLERGIES: No known drug allergies. + +PREOPERATIVE MEDICATIONS: +1. Accupril 40 mg p.o. q. Day. +2. Hydrochlorothiazide 25 mg p.o. q. Day. +3. Toprol XL 50 mg p.o. twice a day. +4. Verapamil SA 240 mg p.o. q. Day. +5. Aspirin 325 mg p.o. q. Day. +6. Plavix 75 mg p.o. q. Day. +7. Lipitor 40 mg p.o. q. Day. +8. Folic acid 1 mg p.o. twice a day. +9. Tums. +10. Multi-vitamin supplements. + + +HOSPITAL COURSE: The patient was admitted to Shaw Medical Center on 2126-10-24 and underwent +cardiac catheterization which showed left ventricular end +diastolic pressure of 17, which rose to 22 after the LV gram; +ejection fraction of 50 percent; 90 percent left main lesion +and patent stents in the left anterior descending, left +circumflex and right coronary artery. The patient was +referred to cardiac surgery for operative management. The +patient was taken to the operating room on 2126-10-25 +with Dr. Soule for coronary artery bypass graft times two; +left internal mammary artery to left anterior descending and +saphenous vein graft to ramus. Total cardiopulmonary bypass +time was 61 minutes; cross clamp time 44 minutes. The +patient was transferred to the Intensive Care Unit in stable +condition. The patient was weaned and extubated from +mechanical ventilation on his first postoperative evening. +On postoperative day number one, the patient was transferred +from the Intensive Care Unit to the regular part of the +hospital. The patient began ambulating with physical +therapy. The patient was started on low dose Lopressor. On +postoperative day number two, the patient's chest tubes and +pacing wires were removed without incident. + +On postoperative day number three, the patient complained of +seeing flashing lights when he was trying to read. He had no +history of this sensation prior. An ophthalmology consult +was obtained. It was determined that the patient's blood +vessels in his eyes were normal. He had a posterior vitreous +detachment in the left eye which required no intervention and +was probably an old finding. They recommended that the +patient follow-up as needed. The patient was restarted on +ace inhibitor for hypertension control. By postoperative day +number four, the patient was able to ambulate 500 feet and +climb one flight of stairs with physical therapy. ON +postoperative day number five, the patient was cleared for +discharge to home. + +CONDITION ON DISCHARGE: Temperature maximum of 100.3; pulse +87 and sinus rhythm; blood pressure 140/90; respiratory rate +16; oxygen saturation 95 percent on room air. The patient's +weight was 95.5 kg. Neurologically, the patient was awake, +alert and oriented times three. Cardiovascular: Regular +rate and rhythm without murmur or rub. Respiratory breath +sounds are decreased at bilateral bases without rhonchi, +wheezes or rales. Abdomen: Soft, nondistended, nontender. +Sternal incision was clean, dry and intact. Sternum is +stable. Right lower extremity vein harvest site with +significant ecchymosis in the right thigh, mildly tender to +palpation. No apparent hematoma. The incision was clean, +dry and intact. + +LABORATORY DATA: White blood cell count of 10.9; hematocrit +of 28.3; platelet count of 316. Sodium of 140; potassium of +3.8; chloride 107; bicarbonate of 24; BUN 14; creatinine 0.7; +glucose 139. + +DISPOSITION: The patient was discharged home in stable +condition. + +DISCHARGE DIAGNOSES: Coronary artery disease. + +Status post coronary artery bypass graft. + +Hypertension. + +DISCHARGE MEDICATIONS: +1. Lasix 20 mg p.o. q. Day times 7 days. +2. Potassium chloride 20 mEq p.o. q. Day times 7 days. +3. Colace 100 mg p.o. twice a day. +4. Zantac 150 mg p.o. twice a day. +5. Aspirin 325 mg p.o. q. Day. +6. Plavix 75 mg p.o. q. Day. +7. Lipitor 40 mg p.o. q. Day. +8. Dilaudid 2 mg tablets, one p.o. every four to six hours + prn. +9. Accupril 40 mg p.o. q. Day. +10. Toprol XL 150 mg p.o. q. Day. + +The patient is to be discharged home in stable condition. He +is to follow-up with his primary care physician, Baker. Soule, +in one to two weeks. He is to follow-up with his +cardiologist, Dr. Soule, in two to three weeks. He is to follow- +up with Dr. Soule in three to four weeks. + + + + + + + + Jacqueline Marcos, M.D. G57933924 + +Dictated By:Halsey +MEDQUIST36 +D: 2126-10-30 18:05:44 +T: 2126-10-30 21:26:14 +Job#: Job Number 31718 +" +"Admission Date: 2176-9-25 Discharge Date: 2176-10-4 + +Date of Birth: Sex: M + +Service: General Surgery + + +DIAGNOSES: +1. Mesenteric venous thrombosis with bowel ischemia and + infarction. +2. Congestive heart failure. +3. Respiratory failure. +4. Sepsis. +5. Tetralogy of Fallot. +6. Down syndrome. +7. Paget disease. +8. Chronic conjunctivitis. +9. Seizure disorder. +10. Peripheral vascular disease. + + +CHIEF COMPLAINT: Respiratory failure with mesenteric +thrombosis. + +HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old +gentleman with Down syndrome and tetralogy of Fallot who +presented to Poe Memorial Hospital Hospital from his group care facility +on 2176-9-22, with complaints of diarrhea, nausea, vomiting +and acute abdominal pain x 48 hours. He was initially +admitted to the medical floor but acutely desaturated and +went into respiratory failure. He required intubation and +was transferred to the ICU. He had bilateral pulmonary +infiltrates. He was started empirically on intravenous +antibiotics and began spiking temperatures and his abdominal +pain worsened. He started passing bright red blood per +rectum and a CT scan was performed, which demonstrated +mesenteric venous thrombosis. He had a hematocrit drop from +43 to 29 and he was transfused for supportive therapy. His +respiratory status deteriorated and he was transferred to the +West Memorial Hospital for further tertiary +care on 2176-9-25. 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 +1. Down syndrome. +2. Congenital heart disease. +3. Tetralogy of Fallot. +4. Paget disease. +5. Chronic conjunctivitis. +6. Seizure disorder. +7. Mental retardation. +8. Depression. +9. Peripheral vascular disease. + +PAST SURGICAL HISTORY: None could be elicited, as the +patient was not responsive. + +MEDICATIONS ON ADMISSION: +1. Dilantin. +2. Ativan. +3. Colace. +4. Aspirin. +5. Valium. +6. Multivitamin. +7. Bacitracin. +8. Lasix. +9. Digoxin. +10.Claritin. +11.Tinactin. +12.Penicillin. +13.Zoloft. +14.Protonix. +15.Vancomycin. + + +ALLERGIES: GENTAMICIN EYE DROPS causing rash. + +SOCIAL HISTORY: He lives in a group home and he is +profoundly retarded and nonambulatory, nonverbal and +frequently combative. He does not drink or smoke. + +PHYSICAL EXAMINATION: His temperature is 101.8, heart rate +88, blood pressure 104/54, he is saturating 96 percent on +assist control with 100 percent FiO2. Generally, he was +sedated, intubated and nonresponsive. His head was +normocephalic. His mucous membranes were dry and he had +nasogastric tube and an endotracheal tube. Reflexes could +not be elicited. His chest had coarse breath sounds +bilaterally with diminishment at the bases. He was without +wheezes or crackles. His heart was regular rate and rhythm +with a 4/6 systolic murmur. His abdomen was distended and +soft. He had no bowel sounds. He had anasarca with pitting +edema in both extremities. His white blood cell count was +11.2. His hematocrit 32, his platelet count 159, 87 +neutrophils, no bands, 9 lymphocytes. Sodium was 150, +potassium was 3.8, chloride was 114, bicarbonate 27, BUN 23, +creatinine 0.9 and glucose 96. His calcium was 8.1, +magnesium was 1.8, phosphorus was 2.2. AST 44, ALT 20, +alkaline phosphatase 77, amylase 73, lipase 13, albumin 2.1, +and total bilirubin 0.4. Blood cultures were taken and a +urine culture was taken. His PT was 16.8 and INR 1.8. His +ABG was pH 7.33, pO2 of 136 and pCO2 of 60. Lactate of 1. + +Chest x-ray showed bilateral fluffy infiltrates about +pneumoperitoneum. + +CT scan was reviewed from the outside hospital and +demonstrated mesenteric venous thrombosis with bowel wall +thickening and ascites. + +CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted +on 2176-9-25, started on intravenous heparin and broad- +spectrum antibiotics. His condition initially improved and +then did plateau. A central line was placed for access for +parenteral nutrition and he was started on parenteral +nutrition. The patient continued to have heme-positive stool +and his hemodynamics secondary to his tetralogy of Fallot and +his ischemia did not improve. Cardiology consult, Vascular +consult and Infectious Disease consult were all obtained. +The patient's condition stabilized but did not significantly +improve over the course of approximately 1 week. After +detailed discussions with the patient's family, it was +decided that no surgery would be performed in the event that +the bowel declared itself as being infarcted rather than +merely ischemic. The patient was transferred to the Medical +Service for supportive therapy. The patient continued with +lack of improvement and the Balmora Organ Bank was +contactJames and the patient was chosen for donation. On +2176-10-4, the patient was taken to the operating room. He +was extubated and declared dead and his organs were +harvested. + + +DATE OF DEATH: 2176-10-4. + + + + Judy Filler, T42279639 + +Dictated By:Gomez MEDQUIST36 +D: 2176-12-17 14:47:01 +T: 2176-12-17 23:06:56 +Job#: Job Number 50984 -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 +" +"Admission Date: 2195-10-19 Discharge Date: 2195-10-19 + +Date of Birth: 2156-3-29 Sex: M + Service: MEDICINE Allergies: -Amiodarone / Quinidine/Quinine +Fish Protein / Shellfish Derived -Attending:Gregory +Attending:Alexis Chief Complaint: -CC:CC Contact Info 94136 -Major Surgical or Invasive Procedure: -hemodialysis +multi-organ failure +Major Surgical or Invasive Procedure: +none 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. +The patient is a 45 y.o. man with pmh significant for +hypertension and obstructive sleep apnea, who presented to an +outside hospital with abdominal pain, shortness of breath, +nausea and vomiting, chest pain, and hematuria. His wife reports +his symptoms began friday when he noticed hematuria. he +presented to the OSH ED, where CT abdomen was unrevealing and he +was told he passed a kidney stone. He went home, where he +developed abdominal pain. His pain was crampy in nature, and +localized over the left lower quadrant. He then developed lower +back pain and shortness of breath, with profound dyspnea on +exertion. Sunday night his abdominal pain was increasing in +severity. He then presented to the Plymel Medical Center ED +Monday Morning. At presentation he had an INR of 4.0, other labs +consistent with DIC, hypotension with systolic blood pressure in +the 60's and oxygen saturation in the 70's. He was reporting +epigastric tenderness. Liver enzymes were also elevated, with T +bili 8.8, Direct Bili 5.5, AST 13,000, ALT 7820, LDH 11,000. +BUN/Cr 20/3.5. He was intubated, given ceftriaxone, levaquin, +and flagyl, and 1L NS, and transferred to Hadley Hospital. On arrival here +he was still hypotensive. A right IJ line was placed. A femoral +arterial line was placed as well. levophed was added and his +blood pressure was 66/34. he was given 5 Liters of NS. +vancomycin and zosyn were added. Initial labs in ED showed pH +6.90/76/86/16, lactate of 14.0. . -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. +On presentation to the ICU he underwent TEE which revealed +hypertrophic obstructive cardiomyopathy, but no aortic +dissection. The patient became asystolic during this procedure +and was coded, receiving CPR, epinephrine, CaCl2, HCO3. . . -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. +He was placed on levophed, vasopressin, neosynephrine. He +received 3 more liters of 150meq sodium HCO3, and is receiving +continuous 150meq NaHCO3. + 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 +Hypertension +Sleep apnea Social History: -SH - Retired psychiatrist. Lives at home with his wife. Quit -tobacco many years ago. No EtOH, no illicits. + drinks one pint of rum or vodka daily, last drink was 4 days +ago. +No cigarettes or tobacco. +No illicit drug use. Family History: -FH - NC +Mother and father with Diabetes. 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. +Vitals: T: BP:115/39 P:115 R:25 O2: 91% on FiO2 100%, TV 600, +PEEP 15, PIP 40. +General: intubated, sedated. obese +HEENT: Sclera anicteric +Neck: obese, difficult to assess. +Lungs: diffuse rhonchi bilaterally +CV: tachycardic, regular, no m/g/r +Abdomen: obese. NT +Ext: poor capillary refill. no edema. + 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 -. +2195-10-19 02:30PM FIBRINOGE-96.6* +2195-10-19 02:30PM PLT COUNT-131* +2195-10-19 02:30PM PT-60.9* PTT-86.4* INR(PT)-6.9* +2195-10-19 02:30PM WBC-17.4* RBC-4.54* HGB-13.9* HCT-44.5 MCV-98 +MCH-30.5 MCHC-31.1 RDW-14.0 +2195-10-19 02:30PM NEUTS-93.6* LYMPHS-4.6* MONOS-1.2* EOS-0.2 +BASOS-0.3 +2195-10-19 02:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-34.5* +bnzodzpn-NEG barbitrt-NEG tricyclic-NEG +2195-10-19 02:30PM CORTISOL-46.4* +2195-10-19 02:30PM D-DIMER->68341 +2195-10-19 02:30PM HAPTOGLOB-20* +2195-10-19 02:30PM ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-11.3* +MAGNESIUM-2.4 +2195-10-19 02:30PM LIPASE-66* +2195-10-19 02:30PM ALT(SGPT)-6680* AST(SGOT)-19417* CK(CPK)-452* +ALK PHOS-144* TOT BILI-8.0* DIR BILI-5.5* INDIR BIL-2.5 +2195-10-19 03:25PM O2 SAT-89 +2195-10-19 03:25PM LACTATE-13.2* + +Micro: +2195-10-19 BLOOD CULTURE Blood Culture, Routine-PENDING +EMERGENCY Perez Clinic +2195-10-19 BLOOD CULTURE Blood Culture, Routine-PENDING +EMERGENCY Perez Clinic + +Imaging: +CT abd/pelvis: +1. Left lower lobe consolidation consistent with pneumonia. In +this location, aspiration is a potential etiology. +2. Fatty liver. +3. Air and decompressed urinary bladder consistent with +instrumentation, +correlate clinically. + +CXR: +support lines remain in place; OGT not completely visualized. +allowing for +portable supine technique and low lung volumes, heart size may +not be +enlarged. left lower lobe consolidation and ill-defined right +perihilar +opacity are as seen on earlier same day CXR and CT abd/pelv. +areas of +consolidation in RUL and LUL somewhat more confluent. no supine +evidence of large ptx or large effusion seen. rt lateral sulcus +excluded. + +TEE: +LVEF 75%, no evidence of aortic dissection -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 +45 year old man with pmh significant for obstructive sleep +apnea, hypertension, presenting with profound lactic acidosis +and hypotension despite three vasopressors. . -#. 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. +#Hypotension: Differential included septic shock, vs. mesenteric +ischemia. Aortic dissection was not found on TEE. CT abdomen was +significant only for mild retroperitoneal fat stranding. +Babesiosis is a possibility given residence on Olympus. Other infectious sources include cholangitis or +cholecystitis given elevated liver enzymes. Patient was +administered broad spectrum antibiotics-vanc, zosyn, flagyl, +doxycycline. He was maintained on vasopressin, phenylephrine, +dopamine, and levophed for pressor support. He was given NaHCO3, +LR for fluids. Patient expired before RUQ ultrasound could be +done. . -# 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 +# Lactic Acidosis: Differential included sepsis and mesenteric +ischemia given history of abdominal cramping pain. He was +maintained on broad spectrum antibiotic. He was not a surgical +candidate in light of his other comorbidities. +. +# Transaminitis: Likely shock liver in setting of reported +hypotension at OSH. Must also consider other liver etiologies, +including acetaminophen, alcoholic hepatitis (given EtOH +history). Serum and urine tox were sent. He did have an +elevated acetaminophen level, which could have contributed to +fulminant hepatic failure especially in light of heavy ETOH use. -Medications on Admission: . -Medications: -Lasix 60 mg a day, Glipizide ER 10 mg, Lipitor 10 mg, Casodex 50 +# DIC: Patient was supported with FFP, cryoprecipitate, and +vitamin K. -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 +# Myocardial infarction: Patient had ST elevations in V1 through +V4, likely secondary to demand ischemia in light of severe +hypotension. + +Patient expired at 20:35 on 2195-10-19. His wife requested autopsy +to determine cause of death. + +Medications on Admission: +amlodipine +celexa +lisinopril -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 +Patient expired Discharge Disposition: -Home with Service +Expired Discharge Diagnosis: -renal failure -hyperkalemia - +pt expired Discharge Condition: -deceased - +pt expired Discharge Instructions: -none +pt expired Followup Instructions: -NA - +pt expired " -"Admission Date: 2182-7-23 Discharge Date: 2182-7-29 +"Admission Date: 2187-8-17 Discharge Date: 2187-8-23 -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. +Service: Orthopedic Surgery -The patient returns now for elective surgery. +HISTORY OF PRESENT ILLNESS: Mrs. Grant is a 87-year-old +woman who was transferred to Blair Clinic from Morris Clinic with a diagnosis of left +intertrochanteric hip fracture. The patient fell earlier on +the day of admission and subsequent to this was unable to +walk secondary to pain. The patient denied weakness, numbness +or paresthesias in left lower extremity. -PAST MEDICAL HISTORY: No known drug allergies. +PAST MEDICAL HISTORY: +1. Hypertension +2. Cataract 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. +1. Toprol +2. Calcium +3. Aspirin 81 mg po q day -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. +ALLERGIES: No known drug allergies. -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. +PHYSICAL EXAM: +GENERAL: Pleasant 87-year-old woman in no acute distress. +VITAL SIGNS: Temperature 98??????, blood pressure 135/80, heart +rate 80, respiratory 18, O2 saturation 98% on room air. +HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and +reactive to light. Oropharynx clear. +LUNGS: Clear to auscultation bilaterally. +HEART: Regular rate and rhythm, no murmurs, rubs or gallops. +ABDOMEN: Soft, nontender, nondistended with positive bowel +sounds. +EXTREMITIES: Left lower extremity was shortened and +externally rotated. There was focal tenderness in the great +trochanter area of the left hip. Strength was 5-13 in left +toes, ankle and knee. Sensation was intact. Pulses were +normal, including popliteal, DP and PT pulses. + +The rest of the physical exam was unremarkable. + +X-RAYS revealed a left intertrochanteric fracture. Chest +x-ray was normal. Electrocardiogram was within normal +limits. + +LABS: White blood cell count was 6.7, hematocrit was 34, +platelets 187. Sodium, potassium chloride, bicarbonate, BUN, +creatinine and glucose were all within normal limits. + +HOSPITAL COURSE: The patient was taken to the Operating Room +on 2187-8-19 and underwent open reduction and internal +fixation of left intertrochanteric fracture. For more +details about the operation, please refer to the operative +note from that date. The patient did not have any +postoperative complications. The operation was under general +anesthesia. + +Preoperatively, the patient was started on Coumadin for deep +venous thrombosis prophylaxis. The patient also received 48 +hours of Kefzol perioperatively. The patient's diet was +advanced as tolerated. The patient was noted to have some +mild difficulty with swallowing and a swallow study consult +was obtained. It was determined the patient did not have any +significant physiological or mechanical problems and those +difficulties were likely due to anxiety the patient was +experiencing postoperatively. The patient eventually +successfully tolerated a regular diet. + +The patient was switched to oral pain medications +successfully. The patient made good progress with physical +therapy and was able to bear weight and walk successfully. +The patient will be discharged to the rehabilitation center. +During the hospital stay, the patient's hematocrit has +remained stable. + +DISCHARGE MEDICATIONS are identical to the medications on +admission, plus Coumadin 2.5 mg po q day for target INR of +1.5. + + + + + David Farber, M.D. R43148808 + +Dictated By:Dylan +MEDQUIST36 -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. +D: 2187-8-22 13:26 +T: 2187-8-22 13:33 +JOB#: Job Number 35270 +" +"Admission Date: 2163-1-10 Discharge Date: 2163-1-19 +Date of Birth: 2090-4-20 Sex: M +Service: SURGERY +Allergies: +Patient recorded as having No Known Allergies to Drugs +Attending:Latonya +Chief Complaint: +N/V +Major Surgical or Invasive Procedure: +None - Charles Wells, M.D. N52931579 -Dictated By:Ellis -MEDQUIST36 +History of Present Illness: +72 M who is 1 week s/p R. colectomy for colon cancer, presents +with increasing nausea and emesis for the past 2 days. He was +discharged 3 days ago, and has had increasing abdominal +distention since. He denies any fever or chills, and reports +continuing to pass flatus. -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 +Past Medical History: +HTN, BPH, GERD, arthritis, monoclonal gammopathy +Social History: +Lives with wife -PRIMARY DIAGNOSIS: Invasive thyroid cancer. -PRIMARY PROCEDURE: Total thyroidectomy, central neck -dissection, resection of cricothyroid membrane. +Family History: +Mother passed away from breast cancer -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. +Physical Exam: +At time of admission: -PAST MEDICAL HISTORY: -1. Urinary stricture. -2. Type 2 diabetes. +97.4 108 95/45 25 94%RA +A&O X 3, conversant +PERRL, EOMI, feculent breath +Heart irregularly irregular +Lungs CTAB +Abd distended, hypertympanic, tender to deep palpation in +epigastrium +Incision C/D/I +Rectal guiac negative +Ext without c/c/e +NGT with 2L feculent output -MEDICATIONS: None +Pertinent Results: +2163-1-10: PT-12.4 PTT-20.4* INR(PT)-1.0 +PLT COUNT-416# WBC-8.1 RBC-3.94* HGB-11.4* HCT-32.7* MCV-83 +MCH-28.8 MCHC-34.8 RDW-13.3 +ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-6.1*# MAGNESIUM-4.2* +CK-MB-7 cTropnT-<0.01 +ALT(SGPT)-53* AST(SGOT)-80* CK(CPK)-377* ALK PHOS-203* +AMYLASE-108* TOT BILI-0.6 +LIPASE-148* -ALLERGIES: No known drug allergies. +Brief Hospital Course: +On 2163-1-10 Mr. Michael was admitted to the surgery service under +the care of Dr. Melancon. He had been discharged 3 days prior +after having a right colectomy for colon cancer. He was +readmitted with a partial SBO, ARF, and new onset of a. fib. He +was initially admitted to the ICU for volume resuscitation and +heart rate control. An NG tube was place and initally put out +over 2 liters of feculent material. After converting in and out +of atrial fibrillation, Mr. Michael was started on amiodarone +and heparin. By HD 3 he remained in sinus rhythm. He was +transferred out of the ICU on HD 6 when is renal status had +improved and his HR and BP were stable. His diet was slowly +advanced after his NGT was removed. During this time he was +treated for a UTI with cipro. He was also started on Zosyn when +an abdominal CT revealed a small fluid collection in the RUQ. He +was transitioned to po Levo and Flagyl. By HD 10, Mr. Michael +was tolerating a regular diet, ambulating with minimal +assistance, and therapeutic on his coumadin. He was discharged +home with instructions to follow-up with his PCP for INR checks, +cardiology, and Dr. Melancon. -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 +Medications on Admission: +atenolol 50', doxazosin 4', amlodipine 5', lisinopril 10', +nexium 40, colace, percocet, klonapin +Discharge Medications: +1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 +times a day). +Disp:*135 Tablet(s)* Refills:*2* +2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One +(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). +Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* +3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times +a day): Please take 2 pills twice a day for 3 days, then 2 pills +once a day for 7 days, and then 1 pill once a day from then on. +Disp:*120 Tablet(s)* Refills:*2* +4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). + +5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). +6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation +Q6H (every 6 hours) as needed. +Disp:*qs 1* Refills:*2* +7. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime: +Adjust dose based on INR. +Disp:*90 Tablet(s)* Refills:*2* +8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every +24 hours) for 4 days. +Disp:*4 Tablet(s)* Refills:*0* +9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 +times a day) for 4 days. +Disp:*12 Tablet(s)* Refills:*0* +10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 5-12 +hours. +Disp:*50 Tablet(s)* Refills:*0* +11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. +Disp:*60 Capsule(s)* Refills:*2* +Discharge Disposition: +Home +Discharge Diagnosis: +Partial small bowel obstruction s/p R. colectomy +New onset A. fib. +Acute renal failure -" -"Admission Date: 2183-12-31 Discharge Date: 2184-1-11 +Discharge Condition: +Good -Service: -ADMISSION DIAGNOSIS: -Right colon cancer. +Discharge Instructions: +Please call your doctor or go to the ER if you experience any of +the following: high fevers >101.5, severe pain, increasing +shortness of breath, chest pain, palpitations, or worsening +nausea/emesis. Please follow-up with your primary care doctor +regarding your coumadin dose. Also please follow-up with +cardiology. -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. +Followup Instructions: +Provider: Geraldine,Crystal Henrietta. 688-710-1461 Follow-up +appointment should be in 2 weeks +Provider: Geraldine,Olga Henrietta. (CARDIOLOGY) 504-466-7865 Call to +schedule appointment +Provider: Geraldine,Crystal Henrietta. (PCP) 870-348-1117 Call to schedule +appointment -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. +" +"Admission Date: 2159-10-9 Discharge Date: 2159-10-16 + +Date of Birth: 2091-9-13 Sex: M + +Service: +HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old +gentleman with a left meningioma diagnosed two weeks prior to +admission. The patient had left head pain with expressive +aphasia and then seizure. He was taken to +Davis Memorial Hospital Hospital where CT of the brain showed this + +PAST MEDICAL HISTORY: Diabetes. + +PAST SURGICAL HISTORY: Bilateral hip replacement, the left +in 2151, the right 2152. Cataract surgery in 2156. + +ALLERGIES: NO KNOWN DRUG ALLERGIES. +PHYSICAL EXAMINATION: General: He was an overweight +gentleman. He was cooperative but a poor historian. HEENT: +Pupils equal, round and reactive to light. Extraocular +movements full. Right palate was soft but did not fully rise +with phonation. His uvula was deviated to the left. Tongue +midline. Smile symmetric. Shoulder shrug intact. Chest: +Rhonchi in the posterior breath sounds and expiratory +wheezes, otherwise clear anteriorly. Cardiovascular: S1 and +S2. Distant heart sounds. Abdomen: Soft, nontender, +nondistended. Negative bruits. Extremities: No edema. He +had 2+ pulses. Gait was unsteady secondary to his hip +replacements. Neurological: Intact. + +LABORATORY DATA: Head CT showed a left frontotemporal dural +based lesion consistent with meningioma. + +HOSPITAL COURSE: The patient underwent a left frontotemporal +craniotomy for excision of meningioma without intraoperative +complications. Postoperatively the patient was agitated and +confused. It was discovered that the patient has a +significant alcohol history. The patient was then +transferred to the Intensive Care Unit for close monitoring +on postoperative day #1 and was given Ativan for DTs. + +He remained in the Intensive Care Unit until 2159-10-13, and was then transferred to the regular floor where he +was seen by Physical Therapy and Occupational Therapy. On +10-16, the patient was found to be safe for discharge +to home with follow-up home physical therapy and occupational +therapy. His mental status cleared. His sitter was +discontinued. He was discharged to home in stable condition. +His staples were removed prior to discharge. His incision +was clean, dry, and intact. + +DISCHARGE MEDICATIONS: He will be weaned from Decadron +starting at 4 mg p.o. q.12 hours and weaned off over 6-7 +days. He is also to remain on Dilantin 200 mg p.o. b.i.d., +Zantac 150 mg p.o. b.i.d. + +FOLLOW-UP: He will follow-up with Dr. Paul in one month. + +CONDITION ON DISCHARGE: He was stable at the time of +discharge. - Richard Lavender, M.D. H33349570 -Dictated By:Jordan + + Stacey Helwig, M.D. P86678299 + +Dictated By:Banks MEDQUIST36 -D: 2184-1-10 22:06 -T: 2184-1-10 22:56 -JOB#: Job Number 104767 +D: 2159-10-16 13:06 +T: 2159-10-16 13:08 +JOB#: Job Number 45663 " -"Name: William, Joshua Unit No: 82021 +"Admission Date: 2177-5-14 Discharge Date: 2177-5-17 -Admission Date: 2125-7-3 Discharge Date: 2125-7-8 +Date of Birth: 2146-7-21 Sex: F -Date of Birth: 2044-5-5 Sex: M +Service: SURGERY -Service: +Allergies: +Dilaudid -ADDENDUM: +Attending:Bruce +Chief Complaint: +ventral hernia -CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM -(CONTINUED): +Major Surgical or Invasive Procedure: +umbilical and ventral hernia repair -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. +History of Present Illness: +30yo female currently on HD, had PD catheter removed in September +2176, with ongoing complaint of pain from an umbilical hernia. -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. +Past Medical History: +- ESRD since 2174-8-29, currently on HD via tunneled line +- Peritonitis 8-7 +- Type I DM complicated by neuropathy and nephropathy +- Bilateral cataract surgeries +- Ventral Hernia -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. +Social History: +- Lives with her mother, + tobacco history, social ETOH, +marijuana use noted in history -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. +Family History: +DM type II, otherwise NC -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. +Physical Exam: +upon admission: +Gen - NAD, AOx3 +CV - RRR, S1/S2 appreciated +Chest - CTAB +Abdomen - soft, nontender, nondistended, well healed PD cath +removal site left abdomen, normal bowel sounds +Ext - no C/C/E -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. +Pertinent Results: +upon admission: +WBC-7.9 RBC-3.72* Hgb-10.9* Hct-34.8* MCV-94 MCH-29.2 MCHC-31.2 +RDW-18.1* Plt Ct-239 +Glucose-78 UreaN-21* Creat-6.4*# Na-144 K-3.6 Cl-104 HCO3-30 +AnGap-14 +Calcium-8.4 Phos-3.3 Mg-2.1 + +2177-5-17 07:30AM BLOOD WBC-7.1 RBC-3.83* Hgb-11.4* Hct-36.3 +MCV-95 MCH-29.9 MCHC-31.5 RDW-17.8* Plt Ct-253 +2177-5-17 04:40AM BLOOD Glucose-122* UreaN-20 Creat-8.5*# Na-140 +K-3.9 Cl-100 HCO3-24 AnGap-20 +Brief Hospital Course: +The patient was admitted to the West-1 surgery for scheduled +ventral/umbilical herniorrhaphy on 2177-5-14, which went well +without complication (please refer to Operative Note for +details). In the PACU, the patient experienced significant pain +control issues as well as nausea and emesis. After +stabilization and improvement in symptoms, the patient was +transferred to the inpatient floor in stable condition. + +Neuro: The patient received dilaudid with adequate pain control, +however patient experienced nausea likely related to narcotic +analgesia. She was transitioned to oxycodone during her +admission after improvement in surgical site pain. + +CV: The patient remained stable from a cardiovascular +standpoint; vital signs were routinely monitored. + +Pulmonary: The patient remained stable from a pulmonary +standpoint; vital signs were routinely monitored. Good pulmonary +toilet, early ambulation and incentive spirrometry were +encouraged throughout hospitalization. + +GI/GU/FEN: Post-operatively, diet was advanced when appropriate +and tolerated. Patient's intake and output were closely +monitored, and IV fluid was adjusted when necessary. +Electrolytes were routinely followed, and repleted when +necessary. Patient underwent scheduled hemodialysis while an +inpatient. + +ID: The patient's white blood count and fever curves were +closely watched for signs of infection. + +Endocrine: Post-operatively, the patient's blood sugar levels +were monitored and a sliding scale implemented. + +Hematology: The patient's complete blood count was examined +routinely; no transfusions were required. + +Prophylaxis: The patient received subcutaneous heparin and +venodyne boots were used during this stay; was encouraged to get +up and ambulate as early as possible. + +At the time of discharge, the patient was doing well, afebrile +with stable vital signs. The patient was tolerating a regular +diet, ambulating, voiding without assistance, and pain was well +controlled. The patient received discharge teaching and +follow-up instructions with understanding verbalized and +agreement with the discharge plan. +Medications on Admission: +Carvedilol 12.5 mg Gaudio Medical Center, Sensipar 30 mg Tdaily, Furosemide 60 mg +daily, Novolog +100 unit/mL Solution per sliding scale QID, Glargine 100 unit/mL +Solution +15 units qhs- fluctuates with appetite and blood sugars, +Lisinopril 20 mg daily, Oxycodone 5 mg Tablet 11-30 every four (4) +hours as needed for pain Sevelamer HCl 800 mg TID with meals, +Travoprost (Benzalkonium) [Travatan] +0.004 % Drops 1 gtt ou hs, Aspirin 81 mg daily, B complex +Vitamins daily, Folic Acid 1 mg daily, - Joseph Nelson, M.D. -I38071681 +Discharge Medications: +1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times +a day). +2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY +(Daily). +4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable +PO DAILY (Daily). +6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). + +7. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY +(Daily). +8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 +times a day). +9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a +day) as needed for constipation. +10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS +(at bedtime). +11. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID +W/MEALS (3 TIMES A DAY WITH MEALS). +12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 +hours) as needed for pain. +Disp:*30 Tablet(s)* Refills:*0* +13. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units +Subcutaneous once a day. +14. Novolog 100 unit/mL Solution Sig: follow sliding scale +Subcutaneous four times a day. +15. Epogen 10,000 unit/mL Solution Sig: One (1) ml Injection +once a week. -Dictated By:Elmer -MEDQUIST36 +Discharge Disposition: +Home With Service -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. +Facility: +South Park Dialysis South Park -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 +Discharge Diagnosis: +ESRD +Ventral hernia repair -Date of Birth: 2068-7-18 Sex: F -Service: #58 +Discharge Condition: +Mental Status: Clear and coherent. +Level of Consciousness: Alert and interactive. +Activity Status: Ambulatory - Independent. -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" +Discharge Instructions: +Please call Dr.Doris office 903-535-3620 if you have any of +the warning signs listed below. +Continue with your usual dialysis schedule +No heavy lifting/straining +No driving while you are taking pain medication + +Followup Instructions: +Provider: James Myers, MD Phone:903-535-3620 +Date/Time:2177-5-30 3:40 +Provider: Ray Alysia, MD Phone:903-535-3620 +Date/Time:2177-6-13 10:40 +Provider: Vickie Michaud, MD Phone:512-597-7329 Date/Time:2177-7-4 +10:40 + + + +Completed by:2177-5-21"