Upload notes_small.csv

notes_small.csv

@@ -47,1089 +47,986 @@ MEDQUIST36
 D:  2130-4-17  08:29
 T:  2130-4-18  08:31
 JOB#:  Job Number 20340"
-"Admission Date:  2143-11-10              Discharge Date:   2143-12-11
+"Admission Date: 2181-6-24        Discharge Date: 2184-7-26
+
+Date of Birth:  2125-9-30        Sex:  M
+
+Service:  Parker
+
+
+HISTORY OF PRESENT ILLNESS:  This is a 55-year-old gentleman
+status post pancreas and kidney in 2164 that was resected in
+2172 and cadaveric renal transplant in 12/99, who had a
+Hartmann pouch, transverse colostomy for diverticulitis in
+1-31, who now presents for preoperative evaluation and bowel
+prep for colostomy takedown tomorrow by Dr. Juan.  No
+fevers or chills.  No shortness of breath, no abdominal pain.
+No other problems with ostomy.
+
+PAST MEDICAL HISTORY:  Diabetes type 1, coronary artery
+disease, status post MI, status post PTCA, multiple coronary
+artery stents, congestive heart failure with an ejection
+fraction of 50 to 55 percent, cardiomyopathy, hepatitis B
+virus, hepatitis C virus, hypothyroidism,
+hypercholesterolemia, benign prostatic hypertrophy,
+peripheral vascular disease, cerebrovascular accident in 2174
+with residual left-sided weakness.
+
+PAST SURGICAL HISTORY:  Status post simultaneous pancreas and
+kidney and cadaveric renal transplant as above, status post
+left femoropopliteal bypass; status post left toe amputations
+1 and 2, status post multiple digit amputations, left 2, 3,
+and 4 and right 5; status post transurethral resection of
+prostate, status post left olecranon open reduction and
+fixation, status post open cholecystectomy, and status post
+Hartmann pouch.
+
+ALLERGIES:  CODEINE AND GENTAMICIN.
+
+OUTPATIENT MEDICATIONS:
+1. Isosorbide 30 mg p.o. q.d.
+2. Prednisone 5 mg p.o. q.d.
+3. Protonix 40 mg p.o. q.d.
+4. Lasix 80 mg p.o. q.d.
+5. Rapamune 1 mg p.o. q.d.
+6. Toprol XL 25 mg p.o. q.d.
+7. Phos-Lo.
+8. Bactrim SS 1 tablet q.d.
+9. Hydralazine 10 mg q.8 h.
+10.      Lantus 15 units and sliding scale insulin.
+
+
+SOCIAL HISTORY:  Lives with wife in Kathryn.  No cigarettes,
+no ETOH.
+
+PHYSICAL EXAMINATION:  On admission, his temperature was 97.8
+degrees, pulse of 60, BP of 150/70, respiratory rate of 18,
+saturation 100 percent on room air.  He was alert and
+oriented x 3, in no apparent distress.  Cardiovascular:
+Regular rate and rhythm without murmurs.  No JVD.  Pulmonary:
+Clear to auscultation bilaterally.  Abdomen:  Soft, positive
+bowel sounds, the left lower quadrant ostomy was pink.
+
+LABORATORY DATA:  His hematocrit on admission was 38.9, white
+count of 3.6, potassium 4.1; creatinine 2.0, baseline 1.5 to
+1.8.
+
+RADIOGRAPHIC STUDIES:  Chest x-ray showed no infiltrates or
+effusions.
+
+HOSPITAL COURSE:  Status post Hartmann take-down, the patient
+was transferred to ICU because the patient required fluid
+resuscitation and pressors, Levophed and vasopressin.  The
+patient did enjoy this slow but steady recovery over his
+hospital stay, complicated by gram-negative rods in his urine
+differentiated as Pseudomonas.  The patient was started on
+Zosyn.  When tested these were specific, it was sensitive to
+meropenem, and he was switched to meropenem.  The patient
+also grew out yeast from urine on 2181-7-21 and is currently
+on fluconazole 200 mg q.d. because of its ability to
+concentrate in the urine.
+
+The Lee Medical Center hospital course also was complicated by a slow
+healing surgical wound that measured approximately 12 x 4 x 2
+cm and it had multiple debridements and wet-to-dry dressings.
+VAC dressings have been applied and will continue after
+discharge.  The patient also has received dialysis while an
+inpatient.  At times insulin management has been difficult.
+He has received Lasix.  When his creatinine peaked at 4.1, he
+was transferred to the Westworld for nesiritide drip for a
+short period of time, which did not seem to benefit him much,
+so he was restarted on dialysis and brought back to the tenth
+floor.
+
+CONSULTATIONS:  Consults include Parker who has helped manage
+his diabetes, Renal with Dr. Guerra who helped manage his
+renal failure, occupational therapy and physical therapy, Dr.
+Jose from cardiology who helped with his nesiritide drip
+and his history of arrhythmias with the management of
+amiodarone, and his endocrinologist for the management of his
+hypothyroidism.
+
+
+
+                        Donna Cordoba, I44721328
+
+Dictated By:Haglund
+MEDQUIST36
+D:  2181-7-27 08:58:53
+T:  2181-7-27 23:28:24
+Job#:  Job Number 
+"
+"Admission Date:  2198-2-8              Discharge Date:   2198-2-20
 
-Date of Birth:  2089-2-6             Sex:   M
+Date of Birth:  2122-5-23             Sex:   F
 
-Service: MEDICINE
+Service: NEUROLOGY
 
 Allergies:
 No Known Allergies / Adverse Drug Reactions
 
-Attending:Griffin
+Attending:Doris
 Chief Complaint:
-Fevers, Altered Mental status
+unresponsive
 
 Major Surgical or Invasive Procedure:
-intubated
+none
 
 History of Present Illness:
-Patient unable to give history himself. Most history is from
-Thomas Memorial Hospital. 54M with a history of CABG, remote MI, hip/shoulder
-surgery, liver failure, hypertension, hyperlipidemia,
-depression, alcohol and tobacco abuse who is transferred from
-Williams Medical Center Hospital after decompensating there. The patient is a
-54-year-old man who was brought into Thomas Memorial Hospital from Quahog detox
-with significant juandice, lethargy, and an episode of syncope
-while exiting the bathroom. At Thomas Memorial Hospital, his initial
-presentation was alert and oriented x 3 and speech clear.
-Pertinent labs at Thomas Memorial Hospital: WBC 19.6 Hct 29 Plt 210 INR 2.7
-Lipase 20 K 3.2 Cl 88 Ammonia 66 Ca 7.9 CO2 37 K 3.2 Total bili
-14.7 Direct bili 10.0 Total protein 6.3 Alb 2.6 AST 213 ALT 23.
-The patient then became febrile to nearly 102 and lethragic,
-only oriented to self. He became agitated as well,
-intermittently. At Thomas Memorial Hospital before transfer the patient had
-received 8mg Ativan, 1gm ceftriaxone, 600mg ibuprofen, 40mg K,
-2g IV MG. The patient's urine output began to drop despite 3L
-NS.
-.
-In the ED, temp 98 Hr 120 Bp 123/84 RR 18 94% RA.  Patient was
-given 1mg ativan for sedation, placed in wrist restraints.
-[x] EKG: sinus tachycardia with nonspecific ST-T changes
-[x] CXR:
-[x] RUQ ultrasound was performed.
-[x] Liver consult was called.
-[x] LFTs:
-[x] UA, Ucx:
-[x] Bcx: pending
-[x] Guaiac: Negative
-[x] ICU transfer requested
-[x] Serum, urine tox, tylenol
-[x] SIRS treatment: vancomycin, cefepime, flagyl
-.
-.
-On the floor, was intermittently agitated. BP was 92/52 HR ws 98
-RR was 14 he was 100%on RA.
-.
-Review of sytems:
-could not be obtained as patient is not cooperative
+The pt is a   75 y/o woman who presents from Hall Clinic
+as OSH transfer for ICH. Limited history obtained at this
+moment. Jean family available. From Records she had pushed her
+lifeline button for unknown reason. EMS arrived to find patient
+with minimal responsiveness. Was taken to OSH where a CT head
+was obtained and found to have a large Left side ICH at the
+basal ganglia. She was transferred here for further care
+intubated. Here she was found to be hypertensive to 245/124. A
+repeat CT head was obtained which showed interval increase in
+blood product with midline shift. Neurosurgery was first
+consulted which they declined an intervention at this moment.
+neurology was asked for
+consultation and she was seen initially on propofol and
+intubated.
 
 Past Medical History:
-Per OSH history:
-history of CABG
-remote MI,
-hip/shoulder surgery,
-liver failure,
-hypertension,
-hyperlipidemia,
-depression,
-alcohol and tobacco abuse
+COPD
+PVD
+Stents in external iliacs
+Hypertension
+Hx of Atrial Fibrillation
+Current smoker
 
-Social History:
-Tunnel worker. Speaking with sister, he drinks close to a quart
-a day of vodka with gatorade. Rooks last drink. Smokes a pack a
-day. Drugs:Wentzel, but may have in the past. He lives with his
-gilfriend
 
+Social History:
+Never married.  Cares for adult son with mental health issues.
+Smoker
 
 Family History:
-unknown.
+unknown
 
 Physical Exam:
-VS: T: 97.9, P: 128, BP: 112/53, RR: 26, 91% RA
-General: Oriented to name only.  Intermittently responsive.
-HEENT: Icteric Sclerae, MMM, oropharynx clear
-Neck: supple, JVP not elevated, no LAD
-Lungs: Clear to auscultation bilaterally, no wheezes, rales,
-rhonchi
-CV: tachycardic, normal S1 + S2,
-Chest: multiple spider angiomas throughout.
-Abdomen: tense, +bowel sounds, non-tender, no rebound tenderness
-or guarding, no organomegaly, without shifting dullness,
-tympanitic on percussion.
-GU: foley in place.
-Ext: mild palmar erythema, warm, well perfused, 2+ pulses, no
-clubbing, cyanosis or edema
-Neuro: A&Ox1, Cranial Nerves intact grossly, good strenght in
-his extremities, profound asterixis.
-
-Discharge
-expired
+Vitals: T:98  BP:245/124  R: 16vent  P:60  SaO2:100%
+General: Intubated, Propofol held x 10 min.
+CV: RRR. Positive murmur. no ventricle heave appreciated.
+Pulm: Slight rhonchi, no crackles at frontal fields.
+EXT: No edema
+Abd: Soft.
+
+Neurologic: Off Propofol for 10 min. eyes closed. Open eyes in
+conjugate gaze (forward). pupils 2mm non reactive. no movement
+to dolls. slight blink to corneal stimulation. Positive cough.
+decerebrate posturing to upper extremity pain stimuli. triple
+flexion at lower extremities. upgoing toes. tone increased in
+all four extremities.
+
 
 Pertinent Results:
-2143-11-10 09:05PM BLOOD WBC-17.9*# RBC-2.74*# Hgb-10.0*#
-Hct-29.1*# MCV-106*# MCH-36.4* MCHC-34.3 RDW-14.0 Plt Ct-171
-2143-11-10 09:05PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0
-Baso-0 Atyps-0 Metas-0 Myelos-0
-2143-11-10 09:05PM BLOOD PT-23.9* PTT-39.2* INR(PT)-2.3*
-2143-11-10 09:05PM BLOOD Glucose-89 UreaN-10 Creat-0.7 Na-137
-K-3.3 Cl-92* HCO3-36* AnGap-12
-2143-11-10 09:05PM BLOOD ALT-24 AST-194* CK(CPK)-65 AlkPhos-261*
-TotBili-14.1* DirBili-9.7* IndBili-4.4
-2143-11-10 09:05PM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.6*
-Mg-1.8 Iron-111
-2143-11-10 09:05PM BLOOD TSH-0.72
-2143-11-11 04:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
-HBcAb-NEGATIVE
-2143-11-11 04:41AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
-2143-11-11 04:41AM BLOOD Dr. Edwards-POSITIVE * Titer-1:40
-2143-11-10 09:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
-Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
-2143-11-11 04:41AM BLOOD HCV Ab-NEGATIVE
-
-discharge
-expired
+Admission Labs
+URINE
+COLOR-Straw APPEAR-Clear SP Gagne-1.009
+BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-100 KETONE-NEG
+BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
+RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-<1
+
+cTropnT-<0.01
+
+2198-2-8 10:18PM   PT-12.5 PTT-21.4* INR(PT)-1.1
+
+GLUCOSE-171* UREA N-19 CREAT-0.7 SODIUM-137 POTASSIUM-3.7
+CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
+CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.2
+
+WBC-13.5* RBC-4.60 HGB-13.2 HCT-39.2 MCV-85 MCH-28.8 MCHC-33.8
+RDW-14.1
+PLT COUNT-243
+
+LACTATE-2.3*
+TYPE-ART TEMP-36.7 PO2-541* PCO2-31* PH-7.48* TOTAL CO2-24 BASE
+XS-1
+
+CT Head Admission
+IMPRESSION:
+1. Increase in 7.1 x 4.5 cm left basal ganglia hemorrhage, with
+extension
+into the left frontal and temporal lobes.
+2. Increased intraventricular hemorrhage, with left lateral
+ventricular
+entrapment and developing hydrocephalus.
+3. Increased midline shift to 5 mm.
+4. Progressive rightward subfalcine herniation to 11 mm.
+5. Early left uncal herniation.
+
 
 Brief Hospital Course:
-54M with a history of remote MI, hip/shoulder surgery, liver
-failure, hypertension, hyperlipidemia, depression, alcohol and
-tobacco abuse who is transferred from Williams Medical Center Hospital with
-fevers, leukocytosis and altered mental status, transferred to
-the ICU for hypoxemic respiratory failure. He expired during
-this admission.
-.
-#Hypoxemic Resp. failure- could have been due to mucous
-plugging, pontine demylination. Regardless he was intubated and
-successfully extubated on the 2144-10-1. He tolerated 40% face
-mask and 4-5 L NC. He was re-intubated after transfer to the ICU
-for respiratory distress again later in his course, believed to
-be related to aspiration. He did not recover, family meeting was
-held and he was made CMO, and expired.
+The pt is a 75 year-old woman with an unknown history is a
+transfer from an OSH for further care regarding a large BG bleed
+likely related to underlying Hypertension.
+
+Neurosurgery was consulted on presentation but it was felt that
+the pt had a devastating hemorrhage and an external ventricular
+drainage and hemicranietomy were
+not an option.  She was managed medically with
+antihypertensives,hypertonic saline and seizure prophylaxis with
+dilantin. EEG showed Periodic Lateralized Epileptiform
+Discharges and Keppra was initiated. She was stable for several
+days but on 2-15 at midnight her left pupil was found blown.
+Hypertonic saline and BP management was continued, Depakote
+started out of concern for continued seizures. Sputum cultures
+returned with moraxella and Levofloxacin was started on 2-17.
+On 2-18, the right pupil was noted to be blown in am. 100g of
+Mannitol given.  She was made 'CPR not indicated' per ICU and
+primary team criteria based on DNR policy. Serum sodium and osm
+continue to trend up and urine output increased; likely due to
+DI.
+
+At noon on 2-20, the patient was noted to become asystolic.  She
+had abrief return of electrical activity without a pulse.
+Before intervention could be made, the heart again went
+asystolic and the patient was declared deceased at 12:10pm.
+
+The patient's nephew and intended guardian, Blanche Octavia,
+declined autospy.
 
 
 Medications on Admission:
-n/a
+None
 
 Discharge Medications:
-expired
+Expired
 
 Discharge Disposition:
 Expired
 
 Discharge Diagnosis:
-expired
+Intracranial hemorrhage
+
 
 Discharge Condition:
-expired
+Expired
 
 Discharge Instructions:
-expired
+Expired
 
 Followup Instructions:
-expired
-
-                             Initials (NamePattern4)  Pereira Sandra MD L41590496
-
-"
-"Admission Date:  2149-11-26              Discharge Date:   2149-11-27
-
-
-Service: MEDICINE
+Expired
 
-Allergies:
-Penicillins
+                             Linda Elma MD N89064582
 
-Attending:Rita
-Chief Complaint:
-Sepsis
-
-Major Surgical or Invasive Procedure:
-ERCP/stent placement
+Completed by:2198-2-20"
+"Name:  Julia, Latosha                    Unit No:  22958
 
-History of Present Illness:
-This is a Age over 90  year old female with hx recent PE/DVT, atrial
-fibrillation, CAD who is transfered from  Allen Clinic Hospital
-for ERCP. She has had multiple admissions to Allen Clinic this
-past month, most recently on 2149-11-20. In early June, she
-presented with back pain and shortness of breath. She was found
-to have bilateral PE's and new afib and started on coumadin. Her
-HCT dropped slightly, requiring blood transfusion, with guaic
-positive stools. She was discharged and returned with abdominal
-cramping and black stools. She was found to have a HCT drop from
-32 to 21. She was given vit K, given a blood transfusion and
-started on protonix. She received an IVF filter and EGD.  EGD
-showed a small gastric and duodenal ulcer (healing), esophageal
-stricture, no active bleeding.  She also had an abdominal CT
-demonstrating a distended gallbladder with gallstones and
-biliary obstruction with several CBD stones. She was started on
-Levo/Flagyl and transfered here for ERCP. Per nursing, her BP
-had been low in 90's at OSH and 80's enroute.
-
-In the ERCP suite, she received vancomycin, Ampicillin and
-Gentamicin as well as Fentanyl. A biliary stent was placed
-successfully in the upper third of the common bile duct. No
-sphincterotomy was done given elevated INR. In addition, a
-single cratered non-bleeding 20mm ulcer was found in the antrum.
+Admission Date:  2106-2-15     Discharge Date: 2106-3-23
 
+Date of Birth:   2024-2-4     Sex:  M
 
-Past Medical History:
-Recent PE/DVT
-Afib
-HTn
-Hypotension
-Hypothyroidism
-CAD
-? mild CHF
+Service:
 
-Social History:
-lives with daughter and granddaughter, functional at home ,
-non-smoker, no alcohol use
+ADDENDUM:  This is an addendum starting 2106-2-15.
 
-Family History:
-NC
+1.  CARDIOVASCULAR:  The patient admitted initially for
+worsening congestive heart failure and was sent to the
+Coronary Care Unit for diuresis with a Swan-Ganz catheter for
+Thundera therapy.  The patient was aggressively diuresed to the
+point of developing hypernatremia and dehydration with
+worsening renal function.  Eventually, the patient was
+discharged to the floor.
 
-Physical Exam:
-GEN: ill appearing, pale, awake but minimally responsive,
-well-nourished, no acute distress
-HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
-rhinorrhea, MMM, OP Clear
-NECK: No JVD, carotid pulses brisk, no bruits, no cervical
-lymphadenopathy, trachea midline
-COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
-PULM: Lungs CTAB, no W/R/R
-ABD: mildly tender abd diffusely w/o rebound or guarding, ND,
-hypoactive bowelsounds, diff to assess HSM, a soft large
-masses/protuberance in RLQ
-EXT: midly swollen left lower ext, no palpable cords
-NEURO: awake, answering some basic questions but not conversant,
-unable to assess orientation
-SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
+From a cardiovascular standpoint, the patient remained stable
+for the rest of his stay; however, when the patient developed
+a respiratory arrest in the hospital on 2106-2-23 the
+patient subsequently became hypotensive requiring multiple
+pressors.  Likely the patient had sepsis physiology.  A
+Swan-Ganz catheter was reintroduced in the Coronary Care Unit
+which showed the patient having elevated cardiac output and
+decreased systemic vascular resistance consistent with septic
+physiology.
 
-Pertinent Results:
-Admission Labs:
-2149-11-26 03:15PM   WBC-11.4* RBC-3.61* HGB-11.3* HCT-32.8*
-MCV-91 MCH-31.3 MCHC-34.5 RDW-17.9*
-2149-11-26 03:15PM   NEUTS-76* BANDS-13* LYMPHS-6* MONOS-3 EOS-0
-BASOS-0 ATYPS-0 METAS-2* MYELOS-0
-2149-11-26 03:15PM   HYPOCHROM-NORMAL ANISOCYT-1+
-POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
-POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
-BURR-OCCASIONAL
-2149-11-26 03:15PM   PLT SMR-NORMAL PLT COUNT-166
-2149-11-26 03:15PM   PT-25.8* PTT-39.2* INR(PT)-2.5*
-2149-11-26 06:12PM   ALT(SGPT)-56* AST(SGOT)-68* LD(LDH)-357* ALK
-PHOS-100 TOT BILI-1.3
-2149-11-26 06:12PM   GLUCOSE-128* UREA N-85* CREAT-2.8* SODIUM-139
-POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-16* ANION GAP-17
-
-Other important labs:
-2149-11-27 03:35AM BLOOD WBC-14.8* RBC-3.15* Hgb-10.0* Hct-28.9*
-MCV-92 MCH-31.9 MCHC-34.8 RDW-17.8* Plt Ct-162
-2149-11-27 03:35AM BLOOD Glucose-81 UreaN-85* Creat-3.0* Na-138
-K-4.4 Cl-107 HCO3-15* AnGap-20
-2149-11-27 03:35AM BLOOD ALT-50* AST-63* AlkPhos-87
-2149-11-27 03:35AM BLOOD Calcium-7.5* Phos-4.8* Mg-1.8
-2149-11-27 10:14AM BLOOD Type-ART Temp-36.7 O2 Flow-4 pO2-101
-pCO2-13* pH-7.20* calTCO2-5* Base XS--20 Intubat-NOT INTUBA
-2149-11-27 10:14AM BLOOD Lactate-10.5*
-
-KUB: Supine film shows gas-filled loops of large and small bowel
-with gas in the region of the rectum. The appearances are
-inconsistent with obstruction and do not suggest ileus
-
-CXR: no failure
-
-RUQ ultrasound: report pending at time of death
+The patient was started on broad spectrum antibiotics and was
+put on multiple pressors including Levophed and pitressin.
+However, after further discussion with the patient's
+daughters, the patient was able to be made comfort measures
+only and pressors were discontinued, and the patient remained
+off pressors until expiration.
 
-Brief Hospital Course:
-Septic from the time of transfer from the OSH for ERCP. Required
-blood pressure support with levophed, which was changed to
-neosynephrine due to elevated HR.  Difficult to volume
-resuscitate given developement of crackles/increasing O2
-requirement with fluid.  Treated with vanc/cipro/flagyl and
-changed to meropenem/vanc. Had stent done by ERCP, but
-sphincterotomy/stone removal not done due to elevated INR.  Most
-likely source of sepsis is biliary/ascending cholangitis.
-Evaluated by General surgery team, who thought she was not a
-surgical candidate and would not recommend IR cholecystostomy
-tube. Lactate rose to 10.5, last ABG 7.2/13/101.  The patient
-complained of significant pain, difficult to control with bolus
-morphine.  Bedside ultrasound was being done to evaluate for
-cholecystitis when the family decided to make the patient CMO
-and the study was stopped. Preliminary report not available at
-the time of death.  The patient was made CMO by her family and
-expired comfortably on a morphine gtt at 16:20 on 2149-11-27.
-Medical examiner declined the case, family declined autopsy.
+2.  PULMONARY:  Again, the patient was doing well until
+hypoxic respiratory arrest on 2106-2-23 thought secondary
+to an aspiration episode.  The patient also with large
+bilateral pleural effusions.  The patient underwent bilateral
+thoracentesis which revealed a transudative fluid secondary
+to congestive heart failure or malnutrition with low oncotic
+pressure.  The patient was initially intubated after his
+respiratory arrest; however, again, after discussion with the
+family, the patient had a terminal extubation and was then
+able to maintain decent saturations with a nonrebreather and
+finally face mask.  The patient was started on a morphine
+drip for comfort.  Unfortunately, the patient eventually
+developed a respiratory arrest and expired.
 
-Medications on Admission:
-ASA 325mg
-Lopressor 25mg Patrick Clinic
-Amiodarone 200mg Patrick Clinic
-Coumadin 2.5mg daily
-Isosorbide 60mg daily
-Levothyroixine 50mcg daily
+3.  INFECTIOUS DISEASE:  The patient initially treated for a
+line sepsis with vancomycin.  However, again, after the
+patient's hypoxic arrest on 2-23, the patient became
+hypotensive; likely secondary to aspiration and multiorgan
+system failure.  The patient was covered with broad spectrum
+antibiotics.  No organisms were cultured.  Again, after
+discussion with the patient's daughters, antibiotics were
+withdrawn and the patient was made comfortable.
 
-Discharge Medications:
-expired
+The patient expired on 2106-3-4.  Time of death at
+7:07 p.m.  The patient had been on a morphine drip titrated
+to comfort prior to expiration.  A family meeting was held
+with both daughters who agreed to this treatment course.  One
+daughter was present at the bedside at the time of
+expiration.  Autopsy was offered but refused.
 
-Discharge Disposition:
-Expired
 
-Discharge Diagnosis:
-Septic shock due to ascending cholangitis
-Choledocholithiasis
-Atrial fibrillation with rapid ventricular response
-Pulmonary emboli
-Deep venous thrombosis
-Upper GI bleed
-Peptic ulcer disease
 
-Discharge Condition:
-expired
 
-Discharge Instructions:
-expired
+                          Sandy Joe, M.D.  U54613350
 
-Followup Instructions:
-expired
+Dictated By:Jammie
 
+MEDQUIST36
 
+D:  2106-3-23  17:37
+T:  2106-3-23  18:55
+JOB#:  Job Number 17745
 "
-"Admission Date:  2182-2-23              Discharge Date:   2182-2-28
+"Admission Date:  2187-8-17       Discharge Date:  2187-8-23
 
 
-Service: SURGERY
+Service:  Orthopedic Surgery
 
-Allergies:
-Patient recorded as having No Known Allergies to Drugs
+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.
 
-Attending:Drew
-Chief Complaint:
-Abdominal pain
+PAST MEDICAL HISTORY:
+1.  Hypertension
+2.  Cataract
 
-Major Surgical or Invasive Procedure:
-ERCP 2182-2-24
+ADMISSION MEDICATIONS:
+1.  Toprol
+2.  Calcium
+3.  Aspirin 81 mg po q day
 
-History of Present Illness:
-This patient is a 84 year old woman who initially presented to
-Jamison Medical Center hospital with 3 day history of abdominal pain. She was
-found to have gallstone pancreatitis and received Levo/flagyl.
-She was subsequently transferred to the Ruiz Memorial Hospital. She has had known
-gallstones for the last 30-40 year without symptoms.
-.
-At Ruiz Memorial Hospital, the patient reported epigastric pain radiating to
-back, nausea, vomiting, chills but no fever. She denied chest
-pain and shortness of breath. She denied jaundice. She had one
-bowel movement on the day prior to presentation.
+ALLERGIES:  No known drug allergies.
 
-Past Medical History:
-PMH:  CAD/MI, HTN, h/o gallstones (no prior symptoms), ""blood
-poisoning"" resulting in trach, breast cancer
-PSH:  CABGx4 '67, appy, hysterectomy, trach, lumpectomy/XRT, B/L
-cataracts
+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.
 
-Social History:
-Quit tobacco 30 years ago
-Rarely drinks EtOH
+The rest of the physical exam was unremarkable.
 
-Physical Exam:
-102.2 76 97/34 22 93% 3l
-NAD, alert and oriented x 3
-neck supple
-CTAB
-RRR
-abdomen mildly distended, tender to percussion/palpation in
-epigastrium, +Dr. Reynolds with guarding
-rectal tone normal, negative guiac at French
-Foley with clear urine
-RLE edema (chronic)
+X-RAYS revealed a left intertrochanteric fracture.  Chest
+x-ray was normal.  Electrocardiogram was within normal
+limits.
 
-Pertinent Results:
-ERCP 2182-2-24: Dilated CBD and PD, Multiple CBD stones and
-biliary pus, Biliary sphincterotomy, Stone extraction, CBD stent
-
-2182-2-23 10:50PM   WBC-9.0 RBC-3.35* HGB-10.6* HCT-30.0* MCV-90
-MCH-31.7 MCHC-35.3* RDW-13.7
-2182-2-23 10:50PM   PLT COUNT-159
-2182-2-23 10:50PM   NEUTS-90.8* BANDS-0 LYMPHS-6.1* MONOS-2.8
-EOS-0.2 BASOS-0.1
-2182-2-23 10:50PM   GLUCOSE-140* UREA N-25* CREAT-1.1 SODIUM-137
-POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13
-2182-2-23 10:50PM   ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-2.0*
-MAGNESIUM-1.6
-
-2182-2-23 10:50PM   ALT(SGPT)-568* AST(SGOT)-537* CK(CPK)-66 ALK
-PHOS-581* AMYLASE-553* TOT BILI-2.9*
+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.
 
-Brief Hospital Course:
-This patient was admitted to the SICU with cholangitis,
-pancreatitis and cholecystitis. In the ED, the patient
-experienced respiratory distress and was intubated. ERCP was
-perfomed at the bedside at which time the findings included:
-Dilated CBD and PD, Multiple CBD stones and biliary pus, Biliary
-sphincterotomy, Stone extraction, CBD stent. In the unit, the
-patient was started on Zosyn, and was supported briefly with
-Levophed. On hospital day #2, the patient was successfully
-extubated. On hospital day #3, she was transferred to the floor.
-Her antibiotics were changed from IV Zosyn to PO
-Levaquin/Flagyl. Her diet was advanced gradually which she
-tolerated well. On hospital day #5 she was cleared by physical
-therapy for discharge to home with services. She was discharged
-in stable condition on hospital day #6. She will continue PO
-Levaquin/Flagyl for 4 days at home and will follow up with Dr.
-Bird in 12-31 weeks for cholecystectomy.
+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.
 
-Medications on Admission:
-Sherwood:  toprol XL 25QD; ASA 325QD; enalapril 10QD; lipitor 5QD;
-fluoxetine prn; xanax 0.5prn; MVI; slo niacin 500QD
+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:
-1. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
-(Daily) for 1 months.
-Disp:*30 Tablet(s)* Refills:*0*
-2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
-times a day) for 4 days.
-Disp:*12 Tablet(s)* Refills:*0*
-3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
-24 hours) for 4 days.
-Disp:*4 Tablet(s)* Refills:*0*
+DISCHARGE MEDICATIONS are identical to the medications on
+admission, plus Coumadin 2.5 mg po q day for target INR of
+1.5.
 
 
-Discharge Disposition:
-Home
 
-Discharge Diagnosis:
-Cholangitis
-Pancreatitis
-Cholecystitis
 
-Discharge Condition:
-Stable, tolerating po
+                            David Farber, M.D.  R43148808
 
-Discharge Instructions:
-worsening abdominal pain, signs of jaundice or any other
-worrisome symptoms.
+Dictated By:Dylan
+MEDQUIST36
 
-Please follow-up as directed.
+D:  2187-8-22  13:26
+T:  2187-8-22  13:33
+JOB#:  Job Number 35270
+"
+"Admission Date:  2198-7-16              Discharge Date:   2198-7-16
 
-Please resume all medications as taken prior to this
-hospitalization. In addition, you should take the antibiotics
-and iron tablets as prescribed.
+Date of Birth:  2132-10-18             Sex:   M
 
-Maintain a low fat diet. For additional nutritional support we
-recomment nutritional supplements such as Boost, Ensure, or
-Resource at breakfast, lunch, and dinner.
+Service: MEDICINE
 
-Continue antibiotics.
+Allergies:
+Patient recorded as having No Known Allergies to Drugs
 
+Attending:Wren
+Chief Complaint:
+black stool
 
-Followup Instructions:
-Provider: Roszel. Kenneth Initial (NamePattern1)  Roszel Phone:942-852-2246
-Date/Time:2182-4-11 9:30
-Provider: William SUITE GI ROOMS Date/Time:2182-4-11 9:30
+Major Surgical or Invasive Procedure:
+Endoscopy
 
-Follow-up with Dr. Bird in 12-31 weeks.  Call her office at
-484-466-8077 to schedule your appointment.
 
+History of Present Illness:
+65 yr old male with hx of crohn's disease who presents to ED
+with one day of dizziness and black diarrhea. Pt states that on
+the afternoon of admission, he acutely developed vertigo and
+nausea and then had an episode of black diarrhea which was
+associated with diaphoresis and near syncope. He notes that a BM
+that morning was darker than normal. Pt denies previous hx of GI
+bleed, no recent NSAID use. No fevers, chills, abd pain.
+*
+In the ED, NG lavage was positive for dark black liquid that did
+not clear with 250cc of normal saline. Pt's HR was initially 112
+to decreased to 80s after fluid; he received a total of 3L in
+the ED. GI service was consulted in ED and attempted EGD but due
+to a large clot in the fundus that could not be mobilized; they
+could not visualize the source of bleeding. He was admitted to
+the MICU overnight for scope in the am.
 
+Past Medical History:
+1. Crohn's disease since age of 24; hx of ileo-cutaneous fistula
+(flares 1-2x/yr)
+2. hx of herniated disk
+3. hx of hip arthritis
+4. HTN
 
-"
-"Admission Date:  2115-5-30     Discharge Date:  2115-6-4
 
-Date of Birth:   2061-3-22     Sex:  F
+Social History:
+occasional alcohol
+previous tobacco hx, quit 16 yrs ago
 
-Service:
 
-ADMISSION DIAGNOSIS:  Breast cancer.
+Family History:
+mother died of ovarian cancer
+father died of pancreatic cancer
+no hx of IBD
 
-DISCHARGE DIAGNOSES:
-1. Breast cancer.
-2. Status post Cranford on the right, mastectomy.
-
-HISTORY OF PRESENT ILLNESS:  The patient is a 54-year-old
-woman who had a recent diagnosis of right breast cancer.
-Core biopsy returned as invasive carcinoma.  The patient had
-a lumpectomy and sentinel node biopsy which were negative but
-with positive margins.  Patient went back for re-excision and
-again had positive margins.  The patient is now consulted for
-a right mastectomy with Cranford, free flap reconstruction.  The
-patient understands all surgical alternatives, and has agreed
-to this decision.
 
-PAST MEDICAL HISTORY:
-1. Mitral valve prolapse.
-2. Status post C section.
-3. Status post right breast biopsy.
-4. Status post right lumpectomy with sentinel node.
+Physical Exam:
+Exam: temp 98.8, BP 95/42, HR 101, R 12, O2 100%RA
+Gen: NAD, AO x 3
+HEENT: PERRL, dry MM
+CV: RRR, nl murmurs
+Chest: clear
+Abd: +BS, soft, NTND; guaic pos black stool
+Ext: 1+ pedal edema
 
-ALLERGIES:  Penicillin and sulfa.
 
-MEDICATIONS:
-1. Vitamins.
-2. Calcium.
-3. Antioxidant.
+Pertinent Results:
+initial HCT = 34.6, dropped to 28.7 then after 2 unit pRBCs and
+3 L IVF returned to Hct 31.4.
 
-PHYSICAL EXAMINATION ON ADMISSION:  Vital signs stable,
-afebrile.  General:  Is in no acute distress.  Chest was
-clear to auscultation bilaterally.  Cardiovascular is
-regular, rate, and rhythm without murmurs, rubs, or gallops.
-Abdomen is soft, nontender, nondistended with no masses or
-organomegaly.  Extremities are warm, noncyanotic,
-nonedematous x4.  Neurologic is grossly intact.
+Brief Hospital Course:
+65 yr old male with hx of crohn's disease who presents with one
+day of melena and dizziness
+.
+1. UGIB: Pt s/p EGD in ED showing nl esophagus, antrum and
+duodenum but a large clot in the fundus that could not be
+mobilized. Per GI recs, given erythromycin x 8hrs to break up
+clot and rescoped in am showing erosions in the pre-pyloric
+region and
+Grade III esophagitis in the gastroesophageal junction.  They
+recommended no aspirin for 4 weeks. Protonix 40 mg before
+breakfast and dinner for one month and then Protonix 40 mg
+before breakfast long term. Patient was discharged on day #2
+with stable hemodynamics and rising hematocrit.
+.
+2. Crohn's disease: stable; continued mercaptopurine outpt dose.
+.
+3. HTN: held felodipine in setting of GI bleed.
 
-HOSPITAL COURSE:  The patient was admitted for semielective
-mastectomy with Cranford on the right reconstruction.  The
-patient was taken to the operating room on 2115-5-30, and had
-the procedure performed as outlined above.  The patient
-tolerated the procedure well without complication in the
-postoperative course, she was immediately placed in the
-Intensive Care Unit for close monitoring.  The patient had
-flap checks per protocol q 30 minutes for the first 12 to 24
-hours followed by q1 hour followed by q2 hour checks.  The
-flap seemed to be doing well, and a Doppler probe was left
-close to the venous outflow postoperatively.  Flap was seen
-to be doing very well, and the patient was transferred to the
-floor on postoperative day #3.  Subsequent to this, the
-patient had an unremarkable hospital stay, and the Doppler
-probe was removed on postoperative day #4, the patient
-subsequently discharged to home.
 
-DISCHARGE CONDITION:  Good.
+Medications on Admission:
+1. Mercaptopurine 50mg qd x 6yrs
+2. ASA 81mg qd
+3. Felodipine 10mg qd
 
-DISPOSITION:  Home.
 
-DIET:  Adlib.
+Discharge Medications:
+1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
+One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
+Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
+2. take all medications as prior to hospitalization.
 
-MEDICATIONS:  Resume all home medications.
-1. Magnesium hydroxide.
-2. Milk of magnesia prn.
-3. Percocet 5/325 1-24 q4-6h prn.
-4. Colace 100 mg Malone Clinic.
-5. Clindamycin 300 mg q6 x7 days.
-6. Enteric coated aspirin 81 mg q day.
+Discharge Disposition:
+Home
 
-DISCHARGE INSTRUCTIONS:  The patient is to followup with Dr.
-Diana in his clinic within one week.  No heavy lifting.
-Patient should return if any problems with either incision
-sites or any signs of cellulitis or infection.
+Discharge Diagnosis:
+Upper GI Bleed
+Erosions
 
 
+Discharge Condition:
+stable
 
+Discharge Instructions:
+Do not take aspirin for at least 4 weeks. Please talk with your
+gastroenterologist before restarting your aspirin.
+Take protonix 40 mg po before breakfast and dinner daily.
 
-                          Joanne Elizondo, M.D.  R87779244
+Followup Instructions:
+Follow up with your gastroenterologist within the next week in
+King's Landing. Please have your hematocrit checked.
 
-Dictated By:George
 
-MEDQUIST36
+                             Initials (NamePattern4)  Ramon Mary MD S16118943
 
-D:  2115-6-3  09:28
-T:  2115-6-3  11:56
-JOB#:  Job Number 49686
 "
-"Admission Date:  2115-2-9              Discharge Date:   2115-2-10
+"Name:  Ava,Jerome                  Unit No:   48768
+
+Admission Date:  2181-7-6              Discharge Date:   2181-7-10
 
-Date of Birth:  2075-6-15             Sex:   F
+Date of Birth:  2132-1-24             Sex:   M
 
 Service: MEDICINE
 
 Allergies:
-Shellfish
-
-Attending:Wendy
-Chief Complaint:
-DKA
-
-Major Surgical or Invasive Procedure:
-None
-
-History of Present Illness:
-39 y/o female with T1DM who presents with weakness and was found
-to be hyperglycemic. Pt reports that she had been feeling weak
-over the past 1-2 days and did not take her insulin for two
-days. Denies F/C. Denies CP or SOB. Denies urinary or bowel
-symptoms. Does admit to N/V. Denies hematemesis, melena, or
-hematochezia. Admits to mild URI symptoms over the past 2 days.
-
-
-In the ED, vitals upon presentation were T 98.6 HR 123 BP 132/69
-RR 19 99%RA. Laboratory testing revealed DKA and she was given a
-bolus of 10 units of regular insulin and started on an insulin
-gtt. She was also aggressively fluid resuscitated with IVF, a
-total of 4L NS. Her FSBG improved to ~240 and she was started on
-D51/2NS. Her symptoms improved dramaticallly. She was also given
-potassium and zofran. CXR was WNL. She was admitted to the ICU
-for further care.
-
-
-Past Medical History:
-Type I Diabetes Mellitus with mild retinopathy, las A1C 10%
-
-
-Social History:
-Former tobacco, quit 9 years ago. Rare EtOH. No IVDU, lives with
-two children. ETOH socially. Works at Rubalcava Clinic as practive
-manager.
-
-
-Family History:
-Grandmother had diabetes and leukemia.  Mother has benign breast
-disease.  Son recently diagnosed with DM type I.
-
-Physical Exam:
-On Presentation:
-
-VSS
-GEN: NAD.
-HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
-rhinorrhea, MMM, OP Clear.
-NECK: No JVD, carotid pulses brisk, no bruits, no cervical
-lymphadenopathy, trachea midline.
-COR: RRR, no M/G/R, normal S1 S2, radial pulses +2.
-PULM: Lungs CTAB, no W/R/R.
-ABD: Soft, NT, ND, +BS, no HSM, no masses.
-EXT: No C/C/E, no palpable cords.
-NEURO: alert, oriented to person, place, and time. CN II ?????? XII
-grossly intact. Moves all 4 extremities. Strength 5/5 in upper
-and lower extremities. Patellar DTR +1. Plantar reflex
-downgoing. No gait disturbance. No cerebellar dysfunction.
-SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses
+Patient recorded as having No Known Allergies to Drugs
 
+Attending:Marjorie
+Addendum:
+Please see attached pertinent results
 
 Pertinent Results:
-CXR: No acute process
+ADMISSION LABS:
+2181-7-6 11:00AM BLOOD WBC-2.5* RBC-3.04* Hgb-10.9* Hct-32.2*
+MCV-106* MCH-35.9* MCHC-34.0 RDW-16.1* Plt Ct-38*
+2181-7-6 11:00AM BLOOD Neuts-53 Bands-1 Lymphs-16* Monos-27*
+Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0
+2181-7-6 11:00AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
+Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL
+Target-1+
+2181-7-6 11:00AM BLOOD Plt Smr-VERY LOW Plt Ct-38* LPlt-1+
+2181-7-6 11:00AM BLOOD PT-14.5* PTT-27.5 INR(PT)-1.3*
+2181-7-6 11:00AM BLOOD Glucose-130* UreaN-6 Creat-0.6 Na-141
+K-4.5 Cl-105 HCO3-25 AnGap-16
+2181-7-6 11:00AM BLOOD CK(CPK)-3133*
+2181-7-6 05:30PM BLOOD ALT-125* AST-504* LD(LDH)-572*
+CK(CPK)-2943* AlkPhos-223* TotBili-2.9*
+2181-7-6 11:00AM BLOOD CK-MB-37* MB Indx-1.2 cTropnT-0.04*
+2181-7-6 11:00AM BLOOD Ethanol-362*
+
+CARDIAC Ballard:
+2181-7-6 11:00AM BLOOD CK(CPK)-3133*
+2181-7-6 05:30PM BLOOD CK(CPK)-2943*
+2181-7-7 02:24AM BLOOD CK(CPK)-2628*
+2181-7-9 04:05AM BLOOD CK(CPK)-1122*
+2181-7-10 06:05AM BLOOD CK(CPK)-668*
+2181-7-6 11:00AM BLOOD CK-MB-37* MB Indx-1.2 cTropnT-0.04*
+2181-7-6 05:30PM BLOOD CK-MB-39* MB Indx-1.3 cTropnT-0.04*
+2181-7-7 02:24AM BLOOD CK-MB-30* MB Indx-1.1 cTropnT-0.04*
+
+HCT TREND:
+2181-7-6 11:00AM BLOOD Hct-32.2*
+2181-7-6 09:30PM BLOOD Hct-28.5*
+2181-7-7 02:24AM BLOOD Hct-27.4*
+2181-7-7 09:28AM BLOOD Hct-32.1*
+2181-7-7 03:18PM BLOOD Hct-31.6*
+2181-7-7 09:15PM BLOOD Hct-32.4*
+2181-7-8 04:00AM BLOOD Hct-33.0*
+2181-7-8 11:53AM BLOOD Hct-32.8*
+2181-7-8 05:15PM BLOOD Hct-34.8*
+2181-7-9 04:05AM BLOOD Hct-33.4*
+2181-7-9 12:10PM BLOOD Hct-34.6*
+2181-7-10 06:05AM BLOOD Hct-33.3*
+
+PLT CT:
+2181-7-6 11:00AM BLOOD Plt Smr-VERY LOW Plt Ct-38* LPlt-1+
+2181-7-7 02:24AM BLOOD Plt Smr-VERY LOW Plt Ct-26*
+2181-7-8 04:00AM BLOOD Plt Ct-56*#
+2181-7-9 04:05AM BLOOD Plt Ct-50*
+2181-7-10 06:05AM BLOOD Plt Ct-51*
+
+IMAGING:
+2181-7-6 R shoulder x-ray: There is no fracture or dislocation.
+Joint
+spaces are normal. There is no degenerative change. Soft tissues
+appear
+normal.
+
+2181-7-6 CXR: Cardiomegaly and new mild pulmonary venous
+congestion. No
+consolidation, mass, or pneumothorax.
+
+2181-7-7 KUB: Supine and decubitus film demonstrated normal bowel
+gas pattern without air-fluid levels. There is no evidence for
+obstruction and no free air is identified.
+
+2181-7-7 Upper endoscopy: Noel Landis tear
+
+2181-7-7 Liver U/S with dopplers: 1. Diffusely echogenic liver
+compatible with patient's known history of cirrhosis.
+Recannulization of the umbilical vein and splenomegaly that is
+also compatible with known cirrhosis. 2. Extremely limited
+Doppler examination secondary to poor penetration. The main
+portal vein is patent with appropriate direction of flow.
+Limited assessment of the right portal vein, the hepatic veins,
+and the right and left hepatic arteries. The main hepatic artery
+is patent with appropriate arterial waveforms.
+
+2181-7-10 CT head: No evidence of acute intracranial hemorrhage
+
+DISCHARGE LABS (2181-7-10):
+2181-7-10 06:05AM BLOOD WBC-4.1 RBC-3.23* Hgb-11.7* Hct-33.3*
+MCV-103* MCH-36.2* MCHC-35.1* RDW-17.8* Plt Ct-51*
+2181-7-10 06:05AM BLOOD Glucose-96 UreaN-5* Creat-0.7 Na-135
+K-3.2* Cl-101 HCO3-27 AnGap-10
+2181-7-10 06:05AM BLOOD CK(CPK)-668* TotBili-5.1*
+2181-7-10 06:05AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.7
 
-Brief Hospital Course:
-39 y/o female with T1DM who presents with weakness and was found
-to be hyperglycemic and in DKA, resolved with insulin gtt,
-fluids and electrolytes.  Discharged home in stable condition on
-home insulin regimen.
+Discharge Disposition:
+Home
 
-# DKA - Unclear precipitant, patients with vague URI and
-abdominal complaints though no diarrhea. Anion gap in 30's on
-admission with kentones in urine. FAggressively fluid
-recussitated with electrolyte repletion with subsequent closeure
-of anion gap to 10. Initially treated with insulin gtt and
-transitioned to home dose of Levemir 35 untis qday and home
-sliding scale. Cultures negative
+                             Barbara Carver MD A91367927
 
-# Ppx:  Received heparin products.
+Completed by:2181-7-15"
+"Name:  William, Joshua                    Unit No:  82021
 
-# Code: full code
+Admission Date:  2125-7-3     Discharge Date:  2125-7-8
 
+Date of Birth:   2044-5-5     Sex:  M
 
-Medications on Admission:
-Zocor 40 mg daily
-Novalog Insulin
-Levemir Insulin
-Flonase PRN
-Aspirin 81 mg daily (although probably only takes 1-2x a week
-because she forgets to take it)
+Service:
 
+ADDENDUM:
 
-Discharge Medications:
-1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
-(Daily).
-2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
-PO DAILY (Daily).
-3. Insulin Detemir 100 unit/mL Solution Sig: Thirty Five (35)
-units Subcutaneous once a day.
-4. Insulin Aspart 100 unit/mL Solution Sig: One (1) unit
-Subcutaneous four times a day: Please take per your sliding
-scale.
-5. Flonase 50 mcg/Actuation Spray, Suspension Sig: 1-2 puffs
-Nasal twice a day as needed for shortness of breath or wheezing.
+CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
+(CONTINUED):
 
+4.  CORONARY ARTERY DISEASE ISSUES:  The patient was switched
+from his home atenolol to metoprolol while in house.  His
+Isordil was held, and he was continued on his home dose of
+Pravachol.
 
+His cardiac enzymes were cycled on admission and remained
+negative.  A repeat cycling of enzymes was done following an
+episode of pulmonary edema.  His troponin T peaked at 0.1,
+but creatine kinase and CK/MB levels remained negative.
 
-Discharge Disposition:
-Home
+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.
 
-Discharge Diagnosis:
-Diabetic Ketoacidosis
+5.  STATUS POST FEMORAL-POPLITEAL BYPASS ISSUES:  For this
+history, the patient received perioperative ampicillin prior
+to undergoing esophagogastroduodenoscopy.
 
+6.  ATRIAL FIBRILLATION ISSUES:  The patient's
+anticoagulation was reversed with fresh frozen plasma and
+vitamin K.  Plan for continuation off of anticoagulation for
+the several weeks considering the severity of his
+gastrointestinal bleed.
 
-Discharge Condition:
-Stable, Afebrile
+CONDITION AT DISCHARGE:  Ambulating independently.  His
+hematocrit remained stable overnight with a discharge
+hematocrit of 36.8.
 
+DISCHARGE STATUS:  The patient was discharged to home.
 
-Discharge Instructions:
-You were admitted to the hospital for your very high blood sugar
-and diabetic ketoacidosis, it is likely you got this as you were
-not able to take your insulin. Whilst in the hospital you were
-started on diabetes medication and your blood sugars were
-monitored carefully. Prior to discharge your labs showed your
-diabetic ketoacidosis had resolved.
+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.
 
-We made no changes to your insulin regimen, please take it as
-prescribed. Please continue taking a diabetic diet.
+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.
 
-Please call Miller Diabetes Centre at 216-684-4607 within the
-next 2 weeks to set up an appointment to see a diabetes
-specialist.
+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.
 
-Please continue to check your blood sugar 4 times a day and take
-your insulin as prescribed to you.
 
-Followup Instructions:
-Please call Miller Diabetes Centre at 546-756-3070 for an
-appointment to see a diabetes specialist within the next two
-weeks.
 
-Provider: Sarah Phone:128-516-1705 Date/Time:2115-4-13 10:00
 
+                          Joseph Nelson, M.D.
+I38071681
 
+Dictated By:Elmer
 
-"
-"Admission Date:  2183-4-21     Discharge Date:  2183-4-30
+MEDQUIST36
 
-Date of Birth:   2122-4-9     Sex:  M
+D:  2125-10-3  17:05
+T:  2125-10-4  07:13
+JOB#:  Job Number 18338
+"
+"Admission Date:  2195-4-21       Discharge Date:  2195-4-26
 
-Service:  UROLOGY Dr. Mccormick
+Date of Birth:   2146-10-25       Sex:  M
 
-HISTORY OF PRESENT ILLNESS:  This is a 61 year old male with
-left renal cell carcinoma admitted status post renal
-embolization by Interventional Radiology, in anticipation for
-a debulking left radical nephrectomy.  Approximately two
-months prior to his presentation, the patient had a chest
-x-ray obtained by primary care physician secondary to Jacqueline
-progressive cough.  The chest x-ray revealed a pulmonary
-nodule.  A chest CT scan was then obtained which revealed
-multiple bilateral pulmonary nodules.  The needle-biopsy was
-consistent with metastatic disease from renal cell carcinoma.
-An abdominal CT scan revealed a 6 cm necrotic left renal
-mass.
+Service:
 
-The patient denied hematuria or bony pain, fever or chills,
-appetite changes or weight loss.  An MRI obtained on 4-10, revealed an 8.1 by 7.1 by 6 cm left renal mass.
+HISTORY OF PRESENT ILLNESS:  The patient is a 48 year old
+gentleman who began having exertional chest pressure in
+May.  He underwent cardiac catheterization on 4-21///02,
+and was found to have severe left main disease with 95%
+stenosis.  The dominant right coronary artery had mild
+proximal disease and a discrete 70% stenosis before the
+bifurcation of the right posterior descending artery.  His
+ejection fraction was 60%.  Intra-aortic balloon pump was
+placed.  The patient was referred to the Cardiac Surgery
+Service on 2195-4-21, for an emergency coronary artery bypass
+graft.
 
 PAST MEDICAL HISTORY:
-1.  Left knee arthroscopy in 2165.
-
-MEDICATIONS:
-Ativan p.r.n.
-
-ALLERGIES:   No known drug allergies.
-
-PHYSICAL EXAMINATION:  Vital signs were temperature of 96.3
-F.; heart rate 69; blood pressure 117/64; respiratory rate
-16; O2 saturation 93% on room air.  Cor:  Regular rate and
-rhythm.  Lungs are clear to auscultation.  Abdomen soft,
-nontender, nondistended.  The patient had renal embolization
-performed on the 25th.  On 4-22, the patient was brought
-to the Operating Room where a left radical nephrectomy was
-performed.  The mass/kidney was adherent to the pancreas but
-was dissected free.  An intraoperative consultation was
-obtained with Dr. Flint.
-
-Postoperatively, the patient was on perioperative Ancef, NG
-tube, Thundera-Metropolis drain, epidural, Foley catheter, PCA,
-chest tube.  The patient was transferred to the Medical
-Intensive Care Unit postoperatively for aggressive fluid
-resuscitation.  On postoperative day one, the patient was
-transferred to the Floor.  By postoperative day two, the
-chest tube was removed.  A chest x-ray obtained after
-removing the chest tube revealed no pneumothorax.
-
-The patient continued to ambulate and await return of bowel
-function.  On postoperative day five, the patient's epidural
-and NG tube were removed.  A Physical Therapy consultation
-was obtained at that time also.  On postoperative day six,
-the patient's Foley catheter was removed.  On postoperative
-day seven, a clear liquid diet was started as the patient
-reported some flatus.  This was tolerated well with no nausea
-or vomiting and therefore the diet was advanced to regular.
-This was also tolerated well.  All of the patient's
-medications were converted to oral form including oral pain
-control.
-
-On postoperative day eight, the Initials (NamePattern4) 228 Jackson-Metropolis drain
-was noted to be minimal, approximately 20 cc per 24 hours.  Initials (NamePattern4) 
-Jackson-Metropolis amylase was sent and the value was 110.
-Therefore, the Thundera-Metropolis was removed.
-
-LABORATORY DATA:  Upon discharge, sodium 139, potassium 3.9,
-chloride 108, bicarbonate 28, BUN 7, creatinine 1.1, glucose
-102.
-
-CONDITION AT DISCHARGE:   Stable.
-
-DISCHARGE MEDICATIONS:
-1.  Percocet one to two tablets p.o. q. four to six hours
-p.r.n. pain.
-2.  Colace 100 mg p.o. twice a day.
-3.  Ativan 1 mg p.o. q. six hours p.r.n.
-
-DISCHARGE STATUS:  Home with home Physical Therapy.
-
-DISCHARGE INSTRUCTIONS:
-1.  The patient will follow-up with Dr. Hosey, in one to two
-weeks.
-
-DISCHARGE DIAGNOSES:
-1.  Status post left radical nephrectomy.
-2.  Metastatic renal cell carcinoma.
-
-
-
-                          Margaret Castro, M.D.  L47035828
+1.  Gastroesophageal reflux disease.
+2.  Headaches.
+3.  Back pain.
+4.  Obesity.
+5.  Sleep apnea, uses CPAP at night.
+6.  Hypercholesterolemia.
+7.  Status post appendectomy.
+8.  Status post tonsillectomy and adenoidectomy.
+9.  Status post right elbow surgery times four.
+10. Status post right knee arthroscopy.
+11. Status post sinus surgery.
 
-Dictated By:Vera
+ALLERGIES:  No known drug allergies.
 
+HOSPITAL COURSE:  The patient was taken to the operating room
+on 2195-4-21, and underwent coronary artery bypass graft times
+four with left internal mammary artery to the left anterior
+descending, saphenous vein graft to the posterior descending
+artery, saphenous vein graft to OM2 to the OM1.  The patient
+tolerated the surgery without complication and was
+transferred to the CSRU.  The patient was extubated overnight
+and his balloon pump was weaned and discontinued on
+postoperative day number one.
+
+He continued to do well and was transferred to the floor on
+postoperative day number two. In the CSRU, he was maintained
+on insulin drip which was discontinued upon arrival to the
+floor, and the patient was then covered with subcutaneous
+regular insulin.  The patient was not requiring insulin prior
+to this hospitalization and Martin consultation was obtained.
+The patient was started on Metformin 500 mg p.o. b.i.d. and
+Glucotrol XL 5 mg p.o. q.d. Margaret Martin consultation.
+
+The patient continued to improve and had no complications.
+He is being discharged to home on postoperative day number
+four.  On discharge, he is afebrile. Vital signs are stable.
+His oxygen saturation is 94% in room air.  His heart rate is
+in the low 80s.  His blood sugar has ranged from 180 to 50.
+On examination, his heart is regular.  His sternum is stable.
+The wounds are clean, dry and intact.  His lungs are clear to
+auscultation bilaterally.  His abdomen is soft, nontender,
+nondistended.  His extremities are warm.
+
+Laboratory data on discharge revealed white count 4.8,
+hematocrit 27.5, and his platelets are 143,000.  His blood
+urea nitrogen is 12 and creatinine is 0.7.  His potassium is
+4.3.
+
+MEDICATIONS ON DISCHARGE:
+1.  Lasix 20 mg p.o. b.i.d. times fourteen days.
+2.  Potassium Chloride 20 meq p.o. b.i.d. times fourteen
+days.
+3.  Colace 100 mg p.o. b.i.d.
+4.  Enteric Coated Aspirin 325 mg p.o. q.d.
+5.  Prilosec 40 mg p.o. q.d.
+6.  Lipitor 20 mg p.o. q.d.
+7.  Paxil 60 mg p.o. q.h.s.
+8.  Nortriptyline 50 mg p.o. q.h.s.
+9.  Lopressor 75 mg p.o. b.i.d.
+10. Metformin 500 mg p.o. b.i.d.
+11. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
+12. Glucotrol XL 5 mg p.o. q.d.
+13. Niferex 150 mg p.o. q.d.
+14. Multivitamin.
+
+The patient is being discharged to home in good condition.
+He is to follow-up with Dr. Margaret Leggett, Dr. Margaret
+Leggett and Dr. Margaret Leggett in two weeks.  He will
+follow-up with Dr. Morgan in six weeks.
+
+
+
+
+                            Peggy Mackey, M.D.  I14414089
+
+Dictated By:Johnson
 MEDQUIST36
 
-D:  2183-4-30  13:35
-T:  2183-4-30  14:01
-JOB#:  Job Number 38115
+D:  2195-4-26  11:17
+T:  2195-4-26  11:35
+JOB#:  Job Number 102917
 "
-"Admission Date:  2187-8-17       Discharge Date:  2187-8-23
+"Admission Date:  2143-3-2              Discharge Date:   2143-3-5
 
+Date of Birth:  2069-1-30             Sex:   F
 
-Service:  Orthopedic Surgery
+Service: 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.
+Allergies:
+No Known Allergies / Adverse Drug Reactions
 
-PAST MEDICAL HISTORY:
-1.  Hypertension
-2.  Cataract
+Attending:Isabel
+Chief Complaint:
+Abdominal pain
 
-ADMISSION MEDICATIONS:
-1.  Toprol
-2.  Calcium
-3.  Aspirin 81 mg po q day
 
-ALLERGIES:  No known drug allergies.
+Major Surgical or Invasive Procedure:
+none
 
-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.
+History of Present Illness:
+ 74 yoF with vascular dementia and history of cadaveric
+kidney transplant at Cannon Memorial Hospital ten years ago, comes form Rolfes Medical Center center where she had been complaining of persistent non
+productive cough and dysuria for one week.  This morning she
+complained of worsening LLQ abdominal pain.  She was brought to
+ED where a CT scan of her abdomen revealed a large 6.6 (TRV) x
+4.5 (AP) x 21.6 (CC) cm rectus sheath hematoma.
 
-X-RAYS revealed a left intertrochanteric fracture.  Chest
-x-ray was normal.  Electrocardiogram was within normal
-limits.
+She is pleasantly demented, and complains only of some mild Left
+sided abdominal pain.  Her daughter, who is with her, reports
+that she has been experiencing a peristent non productive cough
+and dysuria.
 
-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.
+ROS: she denies any chest pain, SOB, headache, vision changes,
+musculoskeletal pain, nausea, vomiting or diarrhea.
 
-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.
+Past Medical History:
+history of DVT bilateral legs 2131 - told by PCP she CANNOT go
+off
+anticoagulation.  Anxiety, frequent UTI, hypercholesterolemia,
+CRF s/p CRT in 2132(?), HTN, vascular dementia.
 
-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.
+PSgH: CRTx in 2132 at Cannon Memorial Hospital.
 
-DISCHARGE MEDICATIONS are identical to the medications on
-admission, plus Coumadin 2.5 mg po q day for target INR of
-1.5.
 
+Social History:
+Lives at Lakeview Alzheimer Unit (Olympus)
 
 
+Physical Exam:
+AAO x 1, pleasantly demented
+RRR no MRG appreciated on auscultation
+CTA B/L no RRW
+Soft, minimally tender in Left side, palpable mass c/w rectus
+sheath hemoatoma on left side, scars c/w prior surgery as above.
++ edema B/L
 
-                            David Farber, M.D.  R43148808
 
-Dictated By:Dylan
-MEDQUIST36
+Brief Hospital Course:
+74 yo F h/o Vascular Dementia, Renal transplant, DVTs on
+coumadin admitted with recuts sheath hematoma on
+supratherapeutic Coumadin. She was admitted and started on
+Vitamin K and give FFP given in ED. Coumadin was held. FFP 4
+units and a total of 3 units of PRBC and 2 units of platelets
+were administered. Serial HCT checks and coags were done until
+stable. Serial abdominal exams were done noting increased
+bruising along left flank and abdomen. Discomfort abated.
+Bruising stopped. Vital signs remained stable. She did not
+requird embolizaton.
+Initially, she was kept NPO, but once stable, diet was resumed
+and tolerated. PT was consulted and noted that patient was at
+baseline. Recommendations were to return to chronic placement at
+alzheimer unit at Lakeview in Olympus.
+
+The decision was made to stop the coumadin given hematoma and
+h/o falls. Information communicated to Dr.Don (PCP)nurse
+(147-240-3018). She was discharged in stable condition back to
+Lakeview off Coumadin.
 
-D:  2187-8-22  13:26
-T:  2187-8-22  13:33
-JOB#:  Job Number 35270
-"
-"Admission Date:  2168-10-24       Discharge Date:  2168-11-3
-
-
-Service:  CARDIOTHORACIC SURGERY
-
-HISTORY OF PRESENT ILLNESS:  This is an 80-year-old physician
-with three vessel disease, left ventricular dysfunction,
-mitral regurgitation, admitted for unstable angina.  Similar
-episode several months ago.  Thrombus in left anterior
-descending, without evidence of plaque rupture.  Exercising
-regularly without angina.  Last night, walked in cold wind,
-gave the patient angina.  During the night, recurrent
-episodes at rest, relieved by nitroglycerin.
-
-PHYSICAL EXAMINATION:  Heart rate 60, blood pressure 140/80.
-Neck:  Jugular venous pressure normal.  Lungs:  Clear to
-auscultation.  Cardiovascular:  II/VI systolic murmur.
-Extremities:  No edema.
-
-LABORATORY DATA:  Troponin less than 0.3, CK 180, MB
-negative.  Electrocardiogram showed stable, no acute changes.
-
-HOSPITAL COURSE:  The patient was admitted on 2168-10-24 to the
-Medrano Medical Center service, where the patient was continued on his aspirin,
-beta blocker, ACE inhibitor, Lipitor and Plavix.  He was
-brought to the cardiac catheterization laboratory on 2168-10-25,
-where they found the LMCA with moderate calcification and
-distal taper to the left anterior descending/RI/LCX of 70%,
-the left anterior descending with an ostial 60% calcified
-lesion, the origin of the D1 with a 50% lesion, left
-circumflex with a non-dominant vessel ostial 80% with
-mid-segment tubular 70% stenosis, and right coronary artery
-with dominant vessel proximally.
-
-Due to the extent of the patient's disease, it was decided
-that he should proceed with coronary artery bypass graft.  On
-2168-10-28, the patient was brought to the operating room, at
-which time a four vessel coronary artery bypass graft was
-performed.  The left internal mammary artery was brought to
-the left anterior descending, saphenous vein graft to the
-diagonal, saphenous vein graft to the obtuse marginal,
-saphenous vein graft to the posterior descending artery.  The
-patient tolerated the procedure well, and was brought to the
-Cardiothoracic Intensive Care Unit.
-
-Postoperatively, the patient continued to do well, and was
-extubated without incident.  The patient maintained his
-pulmonary artery pressure at 31/12, CVP of 9, coronary index
-was maintained at 2.8, and on a milrinone drip at 0.2.
-
-On postoperative day three, the patient was found to be
-maintaining his blood pressure and heart rate without the use
-of drips, and he was subsequently transferred to the Surgical
-floor.  On postoperative day three in the late afternoon, the
-patient converted to atrial fibrillation, at which time he
-was started on amiodarone of 400 three times a day as well as
-given 15 mg of intravenous Lopressor and 2 grams of
-magnesium.  The patient remained in atrial fibrillation for
-the next 48 hours, at which time it was decided to DC
-cardiovert the patient.
-
-On postoperative day six, the patient was brought to the EP
-unit and was cardioverted using 200 joules.  The patient
-converted to normal sinus rhythm and tolerated the procedure
-well.  Amiodarone was subsequently continued.
-
-On postoperative day seven, the patient converted back to
-atrial fibrillation and it was believed at that time that the
-patient should remain rate controlled, so the amiodarone was
-decreased to 200 mg once daily and the patient was started on
-his previous dose of atenolol 25 mg once daily.  The patient
-was heparinized throughout his entire course of atrial
-fibrillation and remained heparinized until his INR reached
-greater than 2.0.
-
-DISCHARGE STATUS:  Good
-
-DISCHARGE DIAGNOSIS:  Status post coronary artery bypass
-graft x 4 complicated by atrial fibrillation
-
-DISCHARGE MEDICATIONS:
-1.  Atenolol 25 mg by mouth once daily
-2.  Amiodarone 200 mg by mouth once daily
-3.  Warfarin 5 mg by mouth once daily
-4.  Calcium carbonate 500 mg by mouth twice a day
-5.  Aspirin 325 mg by mouth once daily
-6.  Colace 100 mg by mouth twice a day
-7.  Lasix 20 mg by mouth every 12 hours for one week
-8.  K-Dur 20 mg by mouth every 12 hours for one week
-
-
-
-
-                            Vanessa Schill, M.D.  I60652135
-
-Dictated By:Nguyen
-MEDQUIST36
 
-D:  2168-11-2  21:06
-T:  2168-11-3  00:00
-JOB#:  Job Number 95629
-"
-"Name:  Julia, Latosha                    Unit No:  22958
+Medications on Admission:
+Garroutte: ativan 0.5 q6 PRN, tylenol, benzonatate 100 TID prn cough,
+robitussin prn cough, namenda 10 q am and 5 q pm, pravastatin 40
+qhs, prednisone 10 q am, citalopram 10 q am, lisinopril 20 q am,
+mycophenolate 1500 Vick Medical Center, donepezil 10 q am, CaCO3 600 Vick Medical Center, MVI,
+Coumadin 2.5 M,F and 3.5 T,W,Th,Sa,Dr. Staples.
 
-Admission Date:  2106-2-15     Discharge Date: 2106-3-23
+ALL: nkda
 
-Date of Birth:   2024-2-4     Sex:  M
 
-Service:
+Discharge Medications:
+1. Discontinued Meds
+Coumadin
+2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
 
-ADDENDUM:  This is an addendum starting 2106-2-15.
+3. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
 
-1.  CARDIOVASCULAR:  The patient admitted initially for
-worsening congestive heart failure and was sent to the
-Coronary Care Unit for diuresis with a Swan-Ganz catheter for
-Thundera therapy.  The patient was aggressively diuresed to the
-point of developing hypernatremia and dehydration with
-worsening renal function.  Eventually, the patient was
-discharged to the floor.
+4. memantine 5 mg Tablet Sig: Two (2) Tablet PO q am ().
+5. memantine 5 mg Tablet Sig: One (1) Tablet PO q pm ().
+6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
+(Daily).
+7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
 
-From a cardiovascular standpoint, the patient remained stable
-for the rest of his stay; however, when the patient developed
-a respiratory arrest in the hospital on 2106-2-23 the
-patient subsequently became hypotensive requiring multiple
-pressors.  Likely the patient had sepsis physiology.  A
-Swan-Ganz catheter was reintroduced in the Coronary Care Unit
-which showed the patient having elevated cardiac output and
-decreased systemic vascular resistance consistent with septic
-physiology.
+8. mycophenolate mofetil 500 mg Tablet Sig: Three (3) Tablet PO
+BID (2 times a day).
+9. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
 
-The patient was started on broad spectrum antibiotics and was
-put on multiple pressors including Levophed and pitressin.
-However, after further discussion with the patient's
-daughters, the patient was able to be made comfort measures
-only and pressors were discontinued, and the patient remained
-off pressors until expiration.
 
-2.  PULMONARY:  Again, the patient was doing well until
-hypoxic respiratory arrest on 2106-2-23 thought secondary
-to an aspiration episode.  The patient also with large
-bilateral pleural effusions.  The patient underwent bilateral
-thoracentesis which revealed a transudative fluid secondary
-to congestive heart failure or malnutrition with low oncotic
-pressure.  The patient was initially intubated after his
-respiratory arrest; however, again, after discussion with the
-family, the patient had a terminal extubation and was then
-able to maintain decent saturations with a nonrebreather and
-finally face mask.  The patient was started on a morphine
-drip for comfort.  Unfortunately, the patient eventually
-developed a respiratory arrest and expired.
+Discharge Disposition:
+Extended Care
 
-3.  INFECTIOUS DISEASE:  The patient initially treated for a
-line sepsis with vancomycin.  However, again, after the
-patient's hypoxic arrest on 2-23, the patient became
-hypotensive; likely secondary to aspiration and multiorgan
-system failure.  The patient was covered with broad spectrum
-antibiotics.  No organisms were cultured.  Again, after
-discussion with the patient's daughters, antibiotics were
-withdrawn and the patient was made comfortable.
+Facility:
+Lakeview
 
-The patient expired on 2106-3-4.  Time of death at
-7:07 p.m.  The patient had been on a morphine drip titrated
-to comfort prior to expiration.  A family meeting was held
-with both daughters who agreed to this treatment course.  One
-daughter was present at the bedside at the time of
-expiration.  Autopsy was offered but refused.
+Discharge Diagnosis:
+Left rectus sheath hematoma
+supra therapeutic inr
+h/o dvts
+h/o renal transplant
 
 
+Discharge Condition:
+Mental Status: Confused - sometimes.
+Level of Consciousness: Alert and interactive.
+Activity Status: Ambulatory - requires assistance or aid (walker
+or cane).
+See PT notes
 
 
-                          Sandy Joe, M.D.  U54613350
+Discharge Instructions:
+You will transfer back to Lakeview in Olympus with
+Smalltown VNA
 
-Dictated By:Jammie
+Followup Instructions:
+follow up with Dr. Vahle in 1 week
 
-MEDQUIST36
 
-D:  2106-3-23  17:37
-T:  2106-3-23  18:55
-JOB#:  Job Number 17745
-"
+
+Completed by:2143-3-5"