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{
"content": "The patient has a family history of prostate cancer and stroke",
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{
"content": " but no history of migraines . <NOTE_END>",
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"content": "He generally looks well . Vital signs are normal . The skin is intact . His head eyes ears nose throat is clear . The neck is without adenopathy . Chest clear . Heart without gallop . Abdomen without mass . Extremities without edema . Neurological examination intact . LABORATORY EXAMINATION hematocrit 33 white count 4.4 with 28 monos and 30 polys and bands . Platelets 253 thousand . Creatinine 0.6 SGOT 52 bilirubin 0.5 . COURSE IN HOSPITAL The patient was hydrated well and given Adriamycin 27 mg and DTIC 450 mg daily for four days . He also got ifosfamide 3.6 grams a day with mesna . He tolerated treatment well and was discharged in good condition . FOLLOWUP by",
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"content": " private physician . LENNI BREUTZOLN M.D. TR by bmot DD 12 10 95 TD <NOTE_END>",
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"content": "Hypothyroidism arthritis hypertension hypercholesterolemia anemia and asthma SURGICAL HISTORY A TAH-BSO in 1980 and an exploratory laparotomy with resection of a pelvic mass in 06 22 MEDICATIONS AT HOME Vicodin 75 750 p.r.n Ultram . Verapamil 240 mg b.i.d. Synthroid 100 mcg q.d HCTZ 25 mg q.d. Arthrotec 0.2 mg b.i.d. 7. Advair 250",
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"content": " 50 mcg one puff q.a.m. Tofranil Ambien 10 mg q.h.s. 10 Trazadone 150 mg q.h.s. 11 Ferrous sulfate 325 mg t.i.d. 12 Colace . <NOTE_END>",
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"content": "The patient was admitted to the Oncology Service on Founder",
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"content": " &aposs 7 and received intravenous chemotherapy with a 72 hour continuous infusion of 5-FU Vinblastine on day 1 and day 3 and Cisplatinum on day 1 . She tolerated the chemotherapy well with mild nausea and vomiting . She had mild increase in her hypertension during the hospitalization likely secondary to fluid overload . She also had some modest anemia at the time of discharge her hematocrit was 30.9 . Overall there were no unanticipated side effects of this chemotherapy . Following her recovery from chemotherapy she will proceed to surgical resection . <NOTE_END>",
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"content": "On presentation her temperature was 98.8 with a heart rate of 100 blood pressure 110 65 respiratory rate 18 and she was saturating at 100 in room air . In general she is well appearing in no acute distress . Head eyes ears nose and throat examination The pupils are equal round and reactive to light and accommodation . Extraocular movements are intact . The oropharynx is negative . Face is stable . No obvious evidence of trauma . She is normocephalic otherwise . Trachea was midline . The heart was regular . The lungs were clear to auscultation bilaterally . No crepitus . The abdomen was soft nontender nondistended . Extremities with no evidence of step-off palpable pulses peripherally . She had brisk capillary refill . Rectal examination was heme negative with normal tone . Neurologic examination was nonfocal . Neurosensory was intact and",
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"content": " she had normal motor examination with 5 5 strength throughout all her upper and lower extremities . <NOTE_END>",
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"content": "The physical examination on transfer showed an alert male with temperature 100 degrees blood pressure 120 64 heart rate 80 . He was intubated with pressor support of 25 and PEEP of 12.5 with 70 FIO2 . Tracheostomy tube",
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"content": " was in good position . There was an audible air leak . His chest showed bilateral rhonchi . The abdomen was distended with active bowel sounds . The rectal examination was unremarkable . Extremities showed trace pulmonary edema . <NOTE_END>",
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"content": "Positive for coronary",
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{
"content": " artery disease and MI . No history of cancer . <NOTE_END>",
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{
"content": "Levoxine 0.125 mg PO q.day Vasotec 10 mg PO",
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{
"content": " b.i.d. Maxzide 75 50 30 mg PO q.day . <NOTE_END>",
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"content": "She was taken to the operating room on 01 16 2003 for decompression at L2 L5 and laminectomy with posterior instrumented fusion at L3 to L5 . She tolerated the surgery well . She was transferred to recovery room in stable condition . She received blood transfusions intraoperatively and postoperatively in addition to autologous blood . Her hematocrit was stable postoperatively . Her neurologic exam was stable postoperatively with 5 5 bilaterally tibial EHL FHL gastroc soleus and intact quadriceps . She has intact sensation L3 to S1 and bilateral lower extremities . She was fitted for Verholl Aet over leg brace and mobilized out of the bed in the brace with physical therapy . Her wounds were stable without any erythema or drainage . She reported nausea on pain medications . Her pain medications were changed around until an acceptable regime was accomplished . She is stable for discharge to rehab . DISCHARGE ACTIVITY She should continue to wear the brace when out of bed and there should be no heavy lifting twisting or bending activities . She will need to follow up with Dr. Uph on 02 21 03 at 930 a.m. DISCHARGE MEDICATIONS Tylenol 650 mg p.o. q.4h. p.r.n. Benadryl 25 mg p.o. q.h.s. p.r.n. Colace 100 mg p.o. q.i.d. Nortriptyline 25 mg p.o. q.h.s. Simvastatin 10 mg p.o. q.h.s. Metamucil one packet p.o. b.i.d. p.r.n. Neurontin 300 mg p.o. t.i.d. Levsinex 0.375 mg p.o. q.12h Lisinopril hydrochlorothiazide 20 25 mg p.o. q.d. hydrocortisone topical ointment to affected areas MS Contin 30 mg p.o. b.i.d. MSIR 15 to 30 mg p.o. q.4h. p.r.n. pain . The patient should continue to have dry sterile dressings to her back and iliac crest wounds until follow up with Dr. Uph",
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"content": " . Should there be any wound erythema or drainage please contact Dr. Uph &aposs office immediately . eScription document 2-7712488 ZNHKjeu Tel Dictated By MAULPLACKAGNELEEB INACHELLE Attending SPACE DOTA Dictation ID 3624752 D <NOTE_END>",
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"content": "He was a chronically ill appearing elderly man",
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"content": " with a respiratory rate of 30 temperature 99.6 pulse 100 and irregularly irregular blood pressure 148 71 . He had some petechiae on his extremities as well as in his mucosal membranes with some hemorrhagic bullae . There were bibasilar rales with some wheezing . He had no cardiac murmur . His abdomen was distended with massive hepatosplenomegaly which was somewhat tender . The neurological examination aside from the blind right eye was unremarkable . <NOTE_END>",
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{
"content": "On",
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"content": " admission included Percocet Prinovil Dapsone Mycelex troches . <NOTE_END>",
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"content": "Nonischemic dilated cardiomyopathy . MEDICATIONS ON DISCHARGE 1. Digoxin 375 mcg and 250 mcg alternating doses each day . Lisinopril 40 mg p.o. q.d. Toprol XL 75 mg p.o. q.d. Flovent 110 mcg two puffs b.i.d. 5. Albuterol 1-2 puffs q.6h. prn . 6. Coumadin 10 mg p.o. q.h.s. Lasix 40 mg p.o. q.d. Keflex 500 mg x6 doses . FOLLOW-UP INSTRUCTIONS The patient will follow",
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"content": " up in EP Clinic on 2012-03-19 . She will also be seen in the Heart Failure Clinic on 2012-03-28 . Patient will also followup with her primary care provider Dr. Sandra Lamar for check of her INR in one week s time . Felix Weiss M.D. 95 -771 Dictated By Randy EB Brooks M.D. MEDQUIST36 D 2012-03-13 1225 T 2012-03-13 1400 JOB 15824 Signed electronically by DR. <NOTE_END>",
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"content": "Toprol 75 mg po bid Furosemide 20 mg po bid times one week potassium chloride 20 mEq po bid while on Lasix Colace 100 mg po bid while on Percocet enteric coated Aspirin 325 mg po q day Indocin 25 mg po bid Sarna cream",
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"content": " applied to affected area prn Percocet 1-2 tabs po q 4-6 hours prn Ibuprofen 400 mg po q 6 hours prn Tylenol 650 mg po q 4-6 hours prn Ativan 0.5 mg po q 8 hours prn . FOAnterP The patient will follow-up in the wound care clinic in two weeks . The patient will also follow-up with Dr. Fairchild her primary care physician in three weeks . The patient will follow-up with Dr. vel Diaz in 3-4 weeks . Briley von der Ross M.D. 67 -576 Dictated By Emily O Ennis M.D. MEDQUIST36 D 2013-01-08 1646 T 2013-01 -08 1708 JOB 67252 Signed electronically by DR. <NOTE_END>",
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"content": "Mr. Hohlt is a 76 year-old man with a history of hypertension hyperlipidemia and prior myocardial infarction with a percutaneous transluminal coronary angioplasty of the right coronary artery in 2005 at the Cambridge Health Alliance . He states that he has experienced pain and tightness in his back radiating into both shoulders starting on 2016-09-02 . The patient denies shortness of breath dizziness diaphoresis or nausea . The pain lasted for 30 seconds following pushing a wheelbarrow and resolved with rest . The patient denied any prior episodes of pain or any since 2005 following the initial episode of pain . The patient informs his primary care provider who referred him to the emergency room . He then presented to Mass. Mental Health Center where he was ruled out for an myocardial infarction by enzymes and electrocardiograms . The patient also underwent a negative evaluation for dissecting aortic aneurysm . On 2016-09-03 the patient began experiencing continuing chest pain of increasing intensity . He was treated with nitroglycerin paste and IV Integrelin as well as Plavix . At that time he ruled in for an NST EMI with a peak CK of 412 and a troponin of 6.23 . Electrocardiograms progressed to inverted T waves in V5 and V6 . The patient is now transferred to Cambridge Health Alliance for cardiac catheterization . PAST MEDICAL HISTORY Hypertension hyperlipidemia IMI in 2005 .",
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"content": " PAST SURGICAL HISTORY Partial thyroidectomy herniorrhaphy percutaneous transluminal coronary angioplasty of the RCA in 2005 left knee surgery as well as tonsil and adenoid surgery . <NOTE_END>",
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"content": "SMA-7 was unremarkable aside form a creatinine of 1.6 and a glucose of 207 otherwise was within normal limits . Hematocrit was 22.4 white count .59 platelets 84. The patient had an absolute neutropenia with a ANC of 318 differential revealed 48 segs 6 bands 40 lymphs 4 monos . Digoxin level was 1.4 . Theo-Dur level was 15 . PT was 12.5 PTT 27.0 . Urinalysis was within",
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"content": " normal limits . Chest x-ray showed enlarged heart with mild pulmonary vascular redistribution no gross congestive heart failure was noted . EKG showed question of MAT vs. atrial fibrillation with a ventricular response of 118 axis was 0 degrees . There was ST scooping in the lateral leads consistent with Dig vs. a question of chronic ischemia changes . There was no significant change from his baseline EKG . <NOTE_END>",
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"content": "Aortic",
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{
"content": " stenosis . Coronary artery disease . Type I diabetes mellitus . Peripheral vascular disease . <NOTE_END>",
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"content": "Severe blunt abdominal trauma with rupture of liver left renal vein pancreas and transverse mesocolon . SPECIAL PROCEDURES AND OPERATIONS 1. 7-2-93 emergency room exploratory laparotomy repair of liver laceration repair of torn transverse mesocolon repair of serosal tear of transverse colon ligation and division of ruptured left renal vein exploration of pancreas 2. 7-4-93 exploratory laparotomy irrigation and debridement pancreatic drainage placement gastrostomy tube jejunostomy cholecystostomy placement of right subclavian Quinton catheter 3. 7-10-93 abdominal irrigation and debridement and packing of pancreas 4. 7-12-93 7-14 7-20 7-22 and 7-24 were the same as 7-10-93 and 7-17 was the same with the addition of tracheostomy were same as 7-10 COMPLICATIONS Severe necrotizing pancreatitis and diffuse peritonitis . MEDICATIONS ON DISCHARGE N A. DOCTORS DISCHARGE ORDERS N A. ESTIMATED DISABILITY AND PROBABLE DURATION",
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"content": " N A. DISPOSITION Mason Street . RISSPA BREATH M.D. TR un bmot DD 08-07-93 TD <NOTE_END>",
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"content": "Imdur 120 mg. PO q.d. Captopril 100mg. PO t.i.d. Lasix 80 mg. PO q.d. Potassium chloride 40 mEq. PO q.d. Coreg 12.5 mg. b.i.d. Cozaar 100 mg. b.i.d. Plavix 75 mg. q.d. Allopurinol 300 mg. q.d. Pulmacort and Serevent inhalers 2 puffs b.i.d. Zocor 20 mg. q.d. Prilosec 20 mg. q.d. Colace 100 mg. t.i.d. FOLLOW UP The patient will see Dr. State as noted in follow up . AKA G STATE M.D. CARDIAC TRANSPLANT STEMSTRICTALLE MEDICAL CENTER Electronically Signed AKA G STATE M.D. 11 17 2000 1246 ?? TR rij",
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"content": " DD 11 09 2000 TD 11 14 2000 109 P cc <NOTE_END>",
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"content": "HCV ETOH Cirrhosis H O SBP Esoph Varices Grade I Depression H O IVDU Heroin Recurrent ARF H O Seizure Chronic LBP Anemia Social History The patient lives with his two sons Charles quit using Cocaine ETOH and IV Heroin two years ago and his son is unaware of any relapses .",
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"content": " He currently smokes about 1 ppd <NOTE_END>",
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"content": "Breast cancer status post lumpectomy Mitral commissurectomy . Atrial fibrillation Peripheral vascular disease . Arterial emboli left femoral artery Congestive heart failure . MEDICATIONS ON TRANSFER Lopressor intravenous q 6 hours . Morphine Sulfate 1 mg intravenous p.r.n. ALLERGIES",
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"content": " Penicillin Sulfa and Quinidine . <NOTE_END>",
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"content": "The patient was admitted to the Verg Medical Center . Subsequent exercise treadmill test demonstrated no evidence of ischemia by EKG . The patient was subsequently taken to the operating room where he underwent a reoperative coronary artery bypass graft times three with a subaortic proximal graft from the aorta to the OM1 and then OM2 and aorta to",
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"content": " the LAD with a wide graft per Dr. Lumar Jongguild . Postoperatively the patient was ventilated . The patient was weaned off an Epinephrine drip . Rhythm became more stable . Balloon was weaned and finally discontinued . The patient was extubated . His Melranon was weaned off and his ACE inhibitor began . The patient was started on Amiodarone and diuresed . The patient &aposs lower extremities began to swell and the patient was begun on Hirudin for deep venous thrombosis . The patient &aposs heparin induced thrombocytopenia became positive and so he is allergic to heparin . The patient was begun on Coumadin and he stayed several days for Coumadinization and was finally discharged on therapeutic Coumadin . The patient tolerated a regular diet on postoperative day number thirteen from his reoperative coronary artery bypass graft . <NOTE_END>",
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"content": "As described above the patient was transfused an additional 2 units in the Intensive Care Unit and the patient also received an upper endoscopy study and her varices were banded .', 'On transfer to the Lemgarson Hospital service her hematocrit was 31.2 white count 11.1 and a platelet count 80 . Her PT was 13.1 PTT 26.7 . The rest of her labs were unremarkable .', 'She was watched very closely while on the floor . She was on GI bleed precautions at all times was too large for IV . She had a clot at the blood bank and she had BID hematocrits checked .', 'She was kept NPO until January 26 when she began to feel hungry . At that time clear liquids were started . All of her stools were guaiaced . She also began Nadolol 40 mg QD to reduce her portal', 'hypertension . The GI consult team continued to follow her . We also tried to contact her physician at Va Sit Namar Healthcare and was unsuccessful . Therefore we decided to work up her cirrhosis .', 'She was described as having cirrhosis and we decided that we wanted to try to figure out the etiology .', 'Her ferritin and iron studies did not reveal any evidence of hemochromatosis and her hep serologies were all negative . She also had negative antimitochondrial antibody and she also had no evidence', 'of ceruloplasmin . Over the course of her admission were also sent an alpha-1-antitrypsin which was negative .', 'She did very well over the course of her admission with no evidence of further bleeding .', 'Her hematocrit stayed stable at approximately 32 . We also did an ultrasound guided paracentesis .', 'The peritoneal fluid showed a glucose of 244 total protein 0.8 and a albumin of 0.5 globulin 0.3 amylase 16 LDH of 51 . The serum albumin gradient was 1.8 consistent with portal hypertension .', 'The cell count showed a white blood cell count of 160 with 16 polys . She therefore criteria for a spontaneous bacterial peritonitis .', 'Her platelet count stayed persistently low and we decided that it might be due to Cimetidine . Therefore we switched her Cimetidine to Prilosec .', 'By the 2th the patient was feeling very well and desired to transfer or discharge to home . She wanted to be closer to North Dakota .', 'After discussion with her private physician Dr. Joasscchird tel. 090-249-6079 at Va Sit Namar Healthcare and Dr. Acrookesjo at Do Of Hospital', 'the patient was judged to be fit for discharge and she was sent home with AH and physical therapy . She was quite able to climb stairs on her own in the hospital .', 'She is to follow up with Dr. Acrookesjo in one week and Dr. Work the gastrointestinal fellow here at",
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"content": " PUOMC in 2 weeks . She may require a repeat upper endoscopy study to see if she needs any rebanding .', 'The patient however complained of a persistent wheeze with beta blocker therefore it was agreed that we would stop the beta blocker until the patient was followed up as an outpatient . <NOTE_END>",
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"content": "On 3-27-93 patient underwent cardiac catheterization coronary and left ventricular angiography without complications . Review of these angiograms demonstrated a dominant right coronary artery with a focal 50 stenosis in the mid-portion . The left main coronary artery was clear . The left anterior descending had moderate plaques with a 50 proximal stenosis of the right anterior oblique caudal view . The proximal diagonal D1 had a 50 stenosis . The circumflex had a long 30 stenosis proximally and an 80 stenosis",
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"content": " at the origin of the second major marginal artery . The left ventricular angiogram showed akinesis of the posterobasal walls severe hypokinesis of the diaphragmatic wall and trace mitral regurgitation . The patient was maintained on heparin anticoagulation . An exercise tolerance test with Thallium was to be performed in order to assess myocardial viability in the infarct zone . The right coronary artery lesion was complex and there was severe stenosis in the obtuse marginal 1 . The patient had no further angina . On 4-2-93 she underwent a Persantine Thallium study . This showed no diagnostic electrocardiogram changes for ischemia and no angina pectoris . The thallium images showed a large region of persistently reduced blood flow involving the apex and inferoposterior segments of the left ventricular wall . This was consistent with scar . There was no definite perfusion abnormality in the circumflex zone . In view of these findings it was elected to discharge her on her present medical program . The patient is to return to the follow up care of Dr. Ko Kollciem at the Diy Hospital . CHPO E. JESCOBEA M.D. TR sq bmot DD 06-13-93 TD <NOTE_END>",
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"content": "Severe blunt abdominal trauma with rupture of liver left renal vein pancreas and transverse mesocolon . SPECIAL PROCEDURES AND OPERATIONS 1. 7-2-93 emergency room exploratory laparotomy repair of liver laceration repair of torn transverse mesocolon repair of serosal tear of transverse colon ligation and division of ruptured left renal vein exploration of pancreas 2. 7-4-93 exploratory laparotomy irrigation and debridement pancreatic drainage placement gastrostomy tube jejunostomy cholecystostomy placement of right subclavian Quinton catheter",
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"content": " 3. 7-10-93 abdominal irrigation and debridement and packing of pancreas 4. 7-12-93 7-14 7-20 7-22 and 7-24 were the same as 7-10-93 and 7-17 was the same with the addition of tracheostomy were same as 7-10 COMPLICATIONS Severe necrotizing pancreatitis and diffuse peritonitis . MEDICATIONS ON DISCHARGE N A. DOCTORS DISCHARGE ORDERS N A. ESTIMATED DISABILITY AND PROBABLE DURATION N A. DISPOSITION Mason Street . RISSPA BREATH M.D. TR un bmot DD 08-07-93 TD <NOTE_END>",
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"content": "UPON ADMISSION TO THE CMED CCU Birth weight was 3850 grams . Head circumference was 41 cm . HEENT was significant for swelling of the scalp tissue in generalized distribution with ecchymosis extending from the occiput to the posterior auricular area and dorsal aspect of the neck to the mid cervical level . Ears were displaced forward . Eyes were normal . Neck and mouth were normal . No nasal flaring . Chest No retractions good breath sounds bilaterally no crackles . Cardiovascular Regular rate and rhythm . Femoral pulses normal S1 S2 were normal . There was a 1 6 systolic ejection murmur in the upper left sternal border without radiation . Abdomen was soft nontender no organomegaly no masses . Bowel sounds are active and patent . CNS active responsive to stimulation . Pupils are reactive to light . Tone is normal moving all limbs symmetrically irritable with palpation of the scalp . Suck root gag grasp and morrow were normal . Skin Pale as above nonicteric . Musculoskeletal Normal spine hip clavicles small mass at the site of previous right quadriceps intramuscular injection . An initial head CT scan had revealed extracranial soft tissue swelling most prominently at the right frontal-parietal-occipital area extending to the left and to the upper cervical region . Ventricles were symmetrical and not compressed . No gross intraparenchymal hemorrhage . But upon further radiology attending Stoughton there was a small bilateral occipital subdural hemorrhage noted . The initial hematocrit was 21.2 platelets 186 . PT was 14.6 PTT 77 with an INR of 1.4 . Fibrinogen was 192 . D-dimer was negative . ASSESSMENT This is a term infant with significant subgaleal hematoma with apparent extension over the past six hours . There was also elevation of the PTT suggesting possible inborn coagulopathy . There is also critical anemia secondary to the subgaleal hemorrhage . He was admitted to the CMED CCU for further management . SUMMARY OF HOSPITAL COURSE BY SYSTEMS 1. Respiratory Patient has been on room air maintaining sats above 95 . No apnea or bradycardia . 2. Cardiovascular There was an initial murmur on admission likely secondary to severe anemia which has since resolved . He remained hemodynamically stable throughout this admission . 3. FEN Patient was restarted on po feeds as of day of life three after the bleeding had stabilized . He has been taking breast milk or Enfamil 20 po adlib . His admission weight was 3850 grams . His weight on discharge was 4055 . 4. GI Given the significant amount of bleeding baby was started prophylactically on phototherapy . His bilirubin peaked on day of life three at 5.4 with a subsequent bilirubin of 4.6 at which time phototherapy was discontinued . 5. Hematology Given the rapid extension of the subgaleal bleed coagulopathy workup was initiated revealing an elevated PTT level of 77 as well as factor 8 level that was below detection in the presence of normal factors 5 9 10 and 11 . He was started on a 50 units kg bolus of factor 8 followed by continuous factor 8 infusions at 50 units kg day divided until hourly infusion rates at 05-10 . Subsequent factor 8 levels varied with an initial factor 8 level of 18 after the bolus with which he received another bolus of factor 8 of 50 units kg and increased factor 8 infusion rate to 65 units kg day . As of 05-17 he was switched over to bolus infusion in preparation of continued home factor 8 administration . His peak level after a bolus of 75 units kg of factor 8 was 131 . A trough level at 20 hours after the bolus on day of discharge was 29 . He will continue to receive factor 8 bolus q day for a total of 2-3",
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"content": " weeks in light of the intracranial hemorrhage and will be followed by Hematology visiting nurse Michael Edwards level checks at home . Currently the infusion of factor 8 are going through a jugular Broviac which was placed on 05-15 for administration of factor . His last PTT on 05-16 was 68.3 . The last hematocrit was on 05-16 of 54.5 . 6. Neurology Baby Mary Stead initially presented with significant subgaleal bleed as well as a small subdural hemorrhage . A repeat head CT scan on 05-15 had shown the resolution of the subdural hematoma and significant improvement of the subgaleal bleed . His head ultrasound on 05-14 reveals no interventricular hemorrhage . He had remained neurologically stable . His head circumference on 05-18 was 36.5 cm with a maximum head circumference on admission of 40.5 cm . 7. Social Both parents are very involved in the care of Baby Norman Stead . They have been informed up to date on his needs discharge from the hospital . Teaching has been completed on the care of the Boviak as well as administration of factor 8 . 8. Sensory Audiology Hearing screen was performed automated auditory brain stem responses and Baby David Stead passed bilaterally . CONDITION ON DISCHARGE Baby Julian Stead had been stable with improvement of the subgaleal bleed and good peak and trough factor 8 levels after the bolus infusion . DISPOSITION Baby Corine Stead is to be discharged home with parents with close Hematology VNA followup . NAME OF PRIMARY PEDIATRICIAN Dr. Pearly Reilly 208-4200 . CARE AND RECOMMENDATIONS Feeds at discharge Breast milk Enfamil 20 po adlib as tolerated . 2. <NOTE_END>",
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"content": "Patient was stable with complete clearance of her mental status advancement of her diet blood pressure and heart rate remained stable and her oxygen saturations were well above 90 during the daytime on 2 liters nasal cannula and at night on the BiPAP settings described above . Physical Therapy consult is pending today . DISCHARGE MEDICATIONS 1. NPH 70 units q.a.m. 50 units q.p.m. Humalog sliding scale . SubQ Heparin 5 000",
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"content": " units t.i.d. Ranitidine 150 mg p.o. b.i.d. Multivitamin x1 . Losartan 25 mg p.o. q.d. Iron supplementation 150 mg p.o. q.d. Levofloxacin day four of 10 to be completed for a full 10-day course 500 mg p.o. q.d. Metoprolol 25 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d. Mark Nibbe M.D. 87 -896 Dictated By Jeffrey N. Elvington M.D. MEDQUIST36 D 2015-10-02 0819 T 2015-10-02 0820 JOB 15790 Signed electronically by DR. <NOTE_END>",
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"content": "White blood cell",
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"content": " count 11.5 hematocrit 31.0 platelet count 290 000 . INR 3.0 . Potassium was 3.0 glucose 131 . MR studies revealed a large left middle cerebral artery infarction with multiple smaller posterior circulation infarctions . <NOTE_END>",
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"content": "The patient is a seventy two year old man who a number of years ago underwent coronary bypass surgery at another institution . This took place in 1983 . In 1992 he underwent redo surgery and aortic valve replacement . In April 1994 he presented with an acute inferior myocardial infarction and was given Streptokinase . He had recurrent pain and went to the Catheter Laboratory where a proximal right coronary artery lesion was angioplastied . A relook several days later led to a repeat percutaneous transluminal coronary angioplasty . He has has stable mild angina subsequently mostly in the setting of stress . Slightly increased in recent months . On the day of admission he was involved in a minor motor vehicle accident and there was some apparent controversy with the driver of the other vehicle during the course of which he developed substernal chest pain radiating to the left arm and shoulder . This waxed and waned for thirty to sixty minutes and he took a number of nitroglycerins . After returning home after conferring with his wife and the pain lasted another half hour he came to the emergency room . His electrocardiogram showed increased T wave inversions in V3 and V4 and 1 mm . ST segment depression in V3 through V6 . His examination was largely benign after he was made pain free . The pulse was 75 blood pressure 120 80 respirations 18 and he was afebrile . The jugular veins were not distended the carotid volume was diminished . The chest was clear and the cardiac rhythm was regular",
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"content": " . There were normal prothetic valves . There was a grade II-II apical and systolic murmur . The abdomen was negative and there was no edema of the feet . <NOTE_END>",
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"content": "Negative for headaches vision changes numbness tingling dyspnea hematuria abdominal pain diarrhea melena or hematochezia . PAST MEDICAL HISTORY Obesity hypertension lower extremity cellulitis and edema breast cancer in 1988 treated with right lumpectomy and XRT partial thyroidectomy in 1963 osteoarthritis with right leg deformities hernia repair 50 years ago bilateral",
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"content": " cataract surgery . ALLERGIES Codeine . <NOTE_END>",
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"content": "The patient was admitted to the Fairm of Ijordcompmac Hospital on the Neurological Surgery Service of Lupevickette L. Ca M.D. Prior to his admission the patient &aposs gunshot wound was sutured",
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"content": " close in the emergency room . The patient was placed on suicide precautions and was hydrated with an infusion of intravenous fluid . The patient was seen in consultation by the Psychiatry Service who began a battery of testing which continues at the time of discharge . The Consulting Psychiatrist recommended a minimum of 2 point restraints at all times and recommended the patient be monitored by a sitter . Allowing the patient to ambulate was not recommended . From a medical standpoint the patient did well . He was initially admitted to the Neurological Intensive Care Unit where he was closely monitored during the first two days of his hospitalization . The chief obstacle was bringing his blood pressure under control and this was ultimately achieved with a combination of Captopril and Nifedipine . After his blood pressure had stabilized the patient was transferred to the Neurology Ward . Close monitoring demonstrated his blood pressure to be stable and within an acceptable rang on his dosage regimen . The Psychiatry Service followed up extensively with the patient and his Psychiatric progress is detailed in the Psychiatry transfer note . By the 7th hospital day the patient was medically stable . He had undergone full Psychiatric evaluation and was prepared for transfer to a Psychiatric Hospital . Therefore because of his need for intense psychiatric care the patient is discharged to the Vo Black Doylestrictshore Ft. Clinics Medical Center on the 7th hospital day . CONDITION ON DISCHARGE Improved . DOCTORS DISCHARGE ORDERS Discharged to Sonpathcermu Jords Hospital . diet as tolerated . Activity ad lib with restrictions as indicated by the Psychiatry Transfer Note . Followup with Dr. Rourdrick in four weeks time . <NOTE_END>",
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"content": "white blood",
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"content": " count 6.2 hemoglobin 12.4 hematocrit 36.1 platelet count 265 000 . The liver function tests were within normal limits . BUN 8 creatinine 0.9 . <NOTE_END>",
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"content": "Temperature was 100.3 F. heart rate was 115 . In general in no acute distress .",
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"content": " Alert and oriented times three . HEENT Extraocular movements are intact . Pupils equally round and reactive to light and accommodation bilaterally . Oropharynx clear . Mucosal membranes are moist . Cardiovascular Regular rate and rhythm normal S1 S2 no murmurs rubs or gallops . Pulmonary clear to auscultation anteriorly . Abdomen soft mildly distended nontender positive bowel sounds . Extremities with no edema one to two pulses in all four extremities . LABORATORY Sodium 141 potassium 4.4 chloride 108 bicarbonate 23 BUN 57 creatinine 0.7 glucose 115 . White blood cell count 11.0 differential with 76 neutrophils 2 monos 21 lymphocytes and no eosinophils . Hematocrit 24.8 platelets 223 INR 2.4 CK 234 . CT scan of the head showed no hemorrhage or edema . EKG showed normal sinus rhythm at 90 with normal intervals and ST wave inversions and early R wave progression . <NOTE_END>",
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"content": "Mr. Factor is a 76 year old white male with acute inferior myocardial infarction who was urgently transferred by Dr. Lenni Factor for cardiac catheterization and possible angioplasty . His only cardiac risk factor includes hypertension . The night of Oct 14 1999 the patient developed chest discomfort associated with shortness of breath . On October 15 1999",
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"content": " at 6 AM the patient was admitted to No Verlmerver Medical Center . An electrocardiogram showed acute inferior myocardial infarction . Due to unknown duration of the chest pain the patient wastransferred urgently to the TGCHO for cardiac catheterization . Shortly after Aggrastat was started the patient became pain free . PAST MEDICAL HISTORY Hypertension and gout . <NOTE_END>",
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{
"content": "No history",
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{
"content": " of GYN cancers or breast cancer . <NOTE_END>",
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{
"content": "Lopressor 25 mg p.o. b.i.d. Lasix 20 mg p.o. q. 12 hours times seven days . 3. Potassium chloride 20 mEq p.o. q. 12 hours times seven days . Colace 100 mg p.o. b.i.d. Metformin 500 mg p.o. b.i.d. Percocet 5 325 one to two tablets p.o. q. four to six hours p.r.n. Celexa 20 mg p.o. q.d. Lipitor 20 mg p.o. q.d. Warfarin 5 mg p.o. q.d. times four days after which point the patient s dosage schedule is to be coordinated by his PCP Dr. Jerold Esqueda . DISCHARGE INSTRUCTIONS The patient is to maintain his incisions clean and dry at all times . The patient may shower but should pat dry incisions afterwards no bathing or swimming until further notice . The patient may resume a Heart Healthy Diet . The patient had been advised to limit his physical exercise no heavy exertion . No driving while taking prescription pain medications . The patient is to have his Coumadin managed by his primary care provider Dr. Jerold Esqueda for a target INR of 2.5 . The patient is to report to Dr. Jones office on 2010-06-14 for an initial blood draw and subsequent Coumadin titration",
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"content": " Coumadin levels are to be monitored per his PCP David . The patient is to follow-up with Dr. Leanne Larimore in Cardiology within two to three weeks following discharge . The patient is to follow-up with Dr. Brenda Hummer four weeks following discharge . The patient is to call to schedule all appointments . Tracy X. Carmen M.D. 76-050 Dictated By Gerald R. Quiroz M.D. MEDQUIST36 D 2010-06-12 0200 T 2010 -06-12 1421 JOB 47222 Signed electronically by DR. Tiffany D. Picklesimer on WED 2010-07-28 <NOTE_END>",
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"content": "He is allergic to Penicillin Inderal and also to Procan . Patient has a seventy pack year history of smoking which he quit ten",
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{
"content": " years ago and he has previously had problems with alcohol . <NOTE_END>",
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"content": "at time of admission the blood pressure 100 65 head eyes ears nose throat no masses neck revealed lymphadenopathy . The lungs were clear heart normal . Abdomen liver",
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"content": " massively enlarged down 15 cm . Extremities normal neurological examination generally intact . <NOTE_END>",
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"content": "The patient is an 84 year old",
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"content": " male with a history of hypertension who was discovered to have an asymptomatic 7 cm abdominal aortic aneurysm on CT scan obtained in the emergency room back in May . At that time he had presented with abdominal pain and was found to have acute cholecystectomy . He underwent an uncomplicated laparoscopic cholecystectomy . He presents at this time for endovascular repair of this abdominal aortic aneurysm . <NOTE_END>",
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"content": "Aspirin 325 mg. PO q.d. Lipitor 80 mg. PO q.d. Toprol XL 50 mg. PO q.d. Lasix 80 mg. q.a.m. and 40 mg. q.p.m. Potassium chloride 20 mEq. PO b.i.d. Citracal 1 packet q.d. Imdur 60 mg. PO q.d. Vitamin E 400 international units q.d. Prilosec 20 mg. PO q.d. HISTORY OF PRESENT ILLNESS Breunlinke is a 70-year-old patient of Dr. Brendniungand Asilbekote in California . She is referred for progressive angina . She had rheumatoid fever as a child and a heart murmur noted but no further testing . She has used antibiotic prophylaxis since 1980 . In 1980 she had quadruple coronary artery bypass graft surgery by Dr. Elks at Feargunwake Otacaa Community Hospital and did well until 1988 when she had exertional angina and a positive stress test and found that three or four grafts were occluded . In October 1989 Dr. No re-did her bypass operation . She had a left internal mammary artery graft to the left anterior descending saphenous vein graft to the obtuse marginal 1 and a saphenous vein graft to the obtuse marginal 2 . In 1993 she had a DDD pacemaker for complete heart block . She had exertional angina at that time . In November 1997 she had a small myocardial infarction as was transferred to Ona Hospital where a cardiac catheterization showed a tight left internal mammary artery to left anterior descending stenosis high grade saphenous vein graft to obtuse marginal 1 stenosis and patent obtuse marginal 2 graft . She had normal left ventricular function with apical tip akinesis . Since that time she has continued to have exertional left chest burning radiating to the left neck and arm relieved by nitroglycerin . She was turned down for re-do surgery at that time and did not have a percutaneous transluminal coronary angioplasty . Because these symptoms have been increasing particularly at cardiac rehabilitation she was referred here . In May 1998 she had an exercise tolerance test in which her heart rate went to 112 and her blood pressure fell to 95 systolic . She had diffuse ischemic ST segment changes and increased lung uptake and a reversible anterior and lateral defect . She has had no syncope . Her cardiac risk factors are hypertension and elevated cholesterol . She has a very strong family history of coronary artery disease with a mother sister and brother",
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"content": " dying of myocardial infarction . She is a remote cigarette smoker . She also has a history of lactose intolerance peptic ulcer disease with a remote gastrointestinal bleed and multiple ectopic pregnancies and mid term miscarriages . She has had a total abdominal hysterectomy . <NOTE_END>",
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"content": "A quantitative V Q scan was also done preoperatively and Pulmonary consult was obtained preoperatively . Pulmonary recommended that he just be started on Albuterol",
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"content": " and Atrovent metered dose inhalers 2 puffs q6h prior to surgery . The patient underwent his procedure on 12-4-93 without complications . Findings included thickened pleura with multiple adhesions and an abscess near the margin major fissure . He had a firm nodule in the left lower lobe . The patient was transferred to the Respiratory Intensive Care Unit in stable condition and had an uneventful stay there . He had oxygen saturations of 99 with an Fi02 of 40 and had no complaints . He was transferred to the floor on postoperative day number one and tolerated his PO&aposs well . His left lower lobe micro results revealed alpha hemolytic Streptococcus on culture and he was then switched to penicillin and Gentamicin after being started on triples of Flagyl Ampicillin and Gentamicin . He had low grade temperatures though did not spike a high temperature during his hospital course . His hospital course was otherwise uneventful and the patient was discharged in stable condition on postoperative day afebrile . The chest X-ray on the morning of discharge was unchanged from the previous day with slight increase in left pleural fluid . He had completed six days of penicillin and Gentamicin and was discharged on Ciprofloxacin and Flagyl for the next seven days . He stayed at the local Comfort Inn before his return back to Aujer Cin . <NOTE_END>",
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"content": "The patient",
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"content": " has no known drug allergies . MEDICATIONS ON ADMISSION Tylenol Ciprofloxacin and Insulin about 16 units of NPH qa.m. <NOTE_END>",
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"content": "Sandostatin 100 mcg subcu. b.i.d. Percocet 1-2 tabs q.3 -4h. p.r.n. pain Axid 150 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d. DISCHARGE FOLLOW-UP The patient has been instructed to follow-up with Dr. Red in one week and in the Urology Clinic in three weeks . DISCHARGE DISPOSITION The patient is discharged to home on 7 10 98 . CONDITION ON DISCHARGE Stable condition . Dictated By MALICHARLEAR KROENER M.D. EB85 Attending LEAND L. KROENER M.D. QW18 FO508 6558 Batch 54270 Index No. YCCYST5DG2",
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"content": " D 07 10 98 T 07 12 98 CC 1. <NOTE_END>",
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"content": "Weight 3.325 kg length was 20 inches i.e. 51 cm head circumference 34.5 cm . Nondysmorphic infant . Active pink newborn in no distress on radiate warmer . Anterior fontanel soft and flat . Palate and clavicles intact . Neck supple . Lungs clear to apex and equal . CARDIOVASCULAR Regular rate and rhythm . No murmurs . 2 femoral pulses . ABDOMEN Soft . Positive bowel sounds . Umbilical cord with Braintree jelly cysts but also with pink tubular discoloration at base . Umbilical ring intact . Normal male . Testes down bilaterally . Patent anus . No sacral anomalies . EXTREMITIES Pink and well perfused . SUMMARY OF HOSPITAL COURSE BY SYSTEMS RESPIRATORY He has been stable in room air throughout hospital course . CARDIOVASCULAR No cardiovascular issues . FLUIDS ELECTROLYTES AND NUTRITION Infant initiated on 60 cc per kg per day of D10W . D-sticks have been stable . Infant is allowed to ad lib breast feed which he is doing vigorously . GASTROINTESTINAL Infant is ad lib feeding . An abdominal ultrasound was performed . Initial impression included omphalocele with further imaging of the bowel to be done . Surgery was consulted and Dr. Boston took patient to OR for exploration of cord on 04-01 . Urachal duct remnanr found removed and bladder repaired . Post op course unremrakable . PAtient began feeding first post op day and has done well . HEMATOLOGY Hematocrit on admission was 52.8 . The infant does not require a new blood transfusion . INFECTIOUS DISEASE CBC and blood culture obtained on admission . Initial CBC had a white count of 20 platelet count of 386 63 polys 2 bands 23 lymphs . Blood cultures remained negative at this time . Infant has not received any antibiotics . NEUROLOGIC Infant has been appropriate",
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"content": " for gestational age . SENSORY Hearing screen has not yet been performed but should be done prior to discharge . CONDITION ON DISCHARGE Stable . DISCHARGE DISPOSITION To Massachusetts General Hospital . NAME OF PRIMARY PEDIATRICIAN Dr. Joan Derringer . DISCHARGE DIAGNOSES Urachal duct remnant . CARE RECOMMENDATIONS Dressing to remain in place for 10 days unless signs of bleeding infection or is soiled . F U with primary pediatricians in 3-4 days or earlier as needed . F U appt with Dr Boston Massachusetts General Hospital Surgery in approx 4 weeks . Mother has Dr Fishmans contact information . Emma Nicolas MD 79-770 Dictated By Jerry E Ross M.D. MEDQUIST36 D 2014-04-01 015751 T 2014-04-01 025913 Job 96281 Signed electronically by DR. James GRAY on Roger 2014-04-03 320 PM <NOTE_END>",
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{
"content": "Levoxine",
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{
"content": " 0.125 mg PO q.day Vasotec 10 mg PO b.i.d. Maxzide 75 50 30 mg PO q.day . <NOTE_END>",
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{
"content": "The patient is a 79-year-old man status postradical cystoprostatectomy with ileal loop for locally invasive prostate cancer . This operation was performed 2 11 02 by Dr. Doje Para . The postoperative course was complicated by atrial fibrillation with transfer to the Cardiac Step-Down Unit . This transfer occurred around postoperative day 8 for anticoagulation and amiodarone load . The anticoagulation was stopped due to concern for postoperative bleeding . The patient complained of fevers . The patient presented to the emergency room on 3 7 02 complaining of fevers",
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"content": " since Monday 3 2 02 . He developed erythema around the wound on Wednesday and was seen by Dr. Para who started Keflex and obtained a CT scan which demonstrated a fluid collection at the site of erythema . The fevers continued as high as 102.5 degrees F with chills on the morning of admission . He was draining pus from the wound site with subsequent relief of discomfort at the site . PAST MEDICAL HISTORY Hypertension atrial fibrillation gout . PAST SURGICAL HISTORY Cystoprostatectomy bilateral inguinal hernia repair . <NOTE_END>",
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"content": "The vital signs showed a temperature of 96.8 heart rate 80 blood pressure 180 78 respiratory",
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"content": " rate 18 and she was satting 95 percent on two liters nasal cannula . In general the patient was resting comfortably in bed with a visible tremor of her right hand and foot . The head eyes ears nose and throat normocephalic atraumatic pupils equal round reactive to light and accommodation extraocular muscles intact sclera anicteric . Neck supple no bruits nodes or thyromegaly . Thorax crackles at both bases kyphotic no costovertebral angle tenderness . Cardiovascular exam regular rate and rhythm with 1 out of 6 systolic ejection murmur . Abdomen soft well healed scar positive bowel sounds no tenderness or organomegaly noted . Extremities without clubbing claudication or edema . Rectal negative per the emergency room . Neurologically the patient was alert and oriented x3 . Tremors of the right hand and foot at rest . Equivocal cogwheeling on the right normal tone on the left . <NOTE_END>",
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"content": "Methylphenidate 5 mg p.o. q.d. Lasix 40 mg p.o. b.i.d. Captopril 50 mg p.o. t.i.d. Glyburide 10 mg p.o. b.i.d. Miconazole powder 2 apply q.i.d. p.r.n. Paxil 20 mg p.o. q.d. Albuterol nebulizer solution one nebulizer q. four hours . Metoprolol 100 mg p.o. t.i.d. Heparin 5 000 units subcutaneously q. 12 hours . Amlodipine 5 mg p.o. b.i.d. Percocet one to two tablets p.o. q. four hours p.r.n. pain . 12. Colace 100 mg p.o. b.i.d. Aspirin 325 mg p.o. q.d. Tube feedings Mr. Knueppel is to be discharged on tube feeds Promote with fiber full-strength at 80 cc per hour around the clock . His PEG tube should be flushed with 30 cc of water after every use . ACTIVITY Mr. Nina activity is ad lib . He is also to be strict n.p.o. He should be n.p.o. until he has a repeat swallow evaluation which demonstrates his ability to swallow without aspiration . FOLLOW-UP The patient will follow-up with Dr. Streeter in his office in four to six weeks . The patient should follow-up with his primary care physician within one week . The patient should follow-up with his orthopedic surgeon at the next convenient time to determine the length of duration of his casting . CONDITION ON DISCHARGE Stable . PHYSICAL EXAMINATION ON DISCHARGE Mr. Knueppel is afebrile with a temperature of 97.1 pulse 77 sinus rhythm . His blood pressure was 142 68 breathing 21 breaths per minute 94 on 2 liters nasal cannula . His pupils were equal round and reactive . Extraocular muscles intact . His head was normocephalic atraumatic . The lungs were clear to auscultation bilaterally . The heart revealed a regular rate and rhythm . The abdomen was soft nontender nondistended",
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"content": " . He had a PEG tube in his left upper quadrant . The site was clean and dry . There was no evidence of necrosis erythema or exudate at the site . The extremities were warm and well perfuse . There was trace edema in both lower extremities . His right lower extremity has ecchymosis related to a saphenectomy site . This ecchymosis is much improved from previous examinations . There was no increased warmth over this area nor is there any exudate from his wounds . All of his wounds including sternotomy wound were clean dry and intact . Timothy M Geibel M.D. 92 -534 Dictated By Melinda U Yantis M.D. MEDQUIST36 D 2014-04-04 0223 T 2014-04-04 1535 JOB 79430 Signed electronically by DR. <NOTE_END>",
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"content": "On admission the patient s vital signs were stable . Her blood pressure was 102 82",
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{
"content": " . Her heart rate was 71 . Her SPO2 was 98 percent on room air . MEDICATIONS ON ADMISSION 1. Plavix 75 mg times 6 doses . Xanax q.d. Prozac 20 mg q.d. Cyclobenzaprine 10 mg q.d. Aspirin 325 mg times 3 doses . Vitamin E . PAST SURGICAL HISTORY Tubal ligation 1986 . Cystectomy 1992 and 1998 . Breast lesion excision 1989 . ALLERGIES TETRACYCLINE . On admission the patient s vital signs were stable . Her blood pressure was 102 82 . Her heart rate was 71 . Her SPO2 was 98 percent on room air . MEDICATIONS ON ADMISSION 1. Plavix 75 mg times 6 doses . Xanax q.d. Prozac 20 mg q.d. Cyclobenzaprine 10 mg q.d. Aspirin 325 mg times 3 doses . Vitamin E . PAST SURGICAL HISTORY Tubal ligation 1986 . Cystectomy 1992 and 1998 . Breast lesion excision 1989 . ALLERGIES TETRACYCLINE . <NOTE_END>",
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{
"content": "He generally looks well . Vital signs are normal . The skin is intact . His head eyes ears nose throat is clear . The neck is without adenopathy . Chest clear . Heart without gallop . Abdomen without mass . Extremities without edema . Neurological examination intact . LABORATORY EXAMINATION hematocrit 33 white count 4.4 with 28 monos and 30 polys and bands . Platelets 253 thousand",
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{
"content": " . Creatinine 0.6 SGOT 52 bilirubin 0.5 . COURSE IN HOSPITAL The patient was hydrated well and given Adriamycin 27 mg and DTIC 450 mg daily for four days . He also got ifosfamide 3.6 grams a day with mesna . He tolerated treatment well and was discharged in good condition . FOLLOWUP by private physician . LENNI BREUTZOLN M.D. TR by bmot DD 12 10 95 TD <NOTE_END>",
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{
"content": "Tylenol 3 Xanax Ciprofloxacin Flagyl . TVI POST M.D. DICTATING",
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{
"content": " FOR REG V. POST M.D. TR xr bmot DD 1-4-94 TD <NOTE_END>",
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"content": "The sodium was 142 potassium 4.5 chloride 105 bicarbonate 27 BUN and creatinine 31 and 1.3 glucose 107 total protein 7.7 albumin 3.2 globulin 4.5 uric acid 4.2 alkaline phosphatase 114 serum glutamic oxaloacetic transaminase 46 lactic acid dehydrogenase 370 white blood count 11 000 with 83 polymorphonuclear leukocytes hematocrit 42 platelet count 227 000 . A chest x-ray showed consolidation bilateral lyin the lower lobes . HOSPITAL COURSE AND TREATMENT The patient was admitted for treatment of a presumed aspiration pneumonia and for rehydration . She was started on Clindamycin and Ofloxacin at renal dose to cover the aspiration pneumonia and positive urine culture which subsequently came back . She had some wheezing which responded well to Albuterol nebulizers . She was generally doing well with resolution of her temperature until 4 1 97 at 920 P.M. when she was noted to be unresponsive with fixed dilated pupils . She was certified dead at 920",
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"content": " P.M. MI CUCHSLI M.D. TR vgo DD 05 11 97 TD 05 15 97 826 Acc MI CUCHSLI <NOTE_END>",
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"content": "The patient was admitted to the surgical intensive care unit where a continued cerebral angiogram was done that was essentially normal without evidence of any obvious aneurysm . The patient was observed for two days with a repeat CT scan showing no changes from the previous examination . The headache stabilized after the patient was transferred to the floor . The patient continued to do well and the decision was",
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"content": " made to discharge him . DISCHARGE INSTRUCTIONS The patient was discharged with strict instructions to return to the emergency room should there be an exacerbation of symptoms . CONDITION ON DISCHARGE Stable . DISCHARGE DIAGNOSES Ruled out subarachnoid hemorrhage . Michael Lawrence M.D. 41 -707 Dictated By Lena D. Mannie M.D. MEDQUIST36 D 2014-08-09 1404 T 2014-08-09 1527 JOB 45402 Signed electronically by DR. Michael Jackson on FRI 2014-09-05 1139 AM <NOTE_END>",
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{
"content": "No known drug allergies . MEDICATIONS ON ADMISSION According to his pharmacy he was on 1. OxyContin",
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{
"content": " 40 mg p.o. q 12hours . Percocet . Nortriptyline . Neurontin 1800 mg four times a day <NOTE_END>",
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{
"content": "The patient was transferred to Medical Intensive Care Unit for further management for acute GI bleed . 1. Gastrointestinal bleed The patient continued to receive blood transfusions on the floor and serial hematocrits with serial INR checks were drawn . As he was receiving his third unit of packed red blood cells the patient became tachycardic and short of breath . His temperature raised from 98.6 F. to 101.0 F. He was shown to have rigors . The transfusion was stopped and the patient was given Tylenol 1 mg with epinephrine 100 mg of hydrocortisone 25 mg of Benadryl and Demerol 15 as well as Pepcid . He had emesis times three of 75 cc of coffee ground material . The patient also desaturated to the low 80 s and was started on a non-rebreather mask . His saturations improved quickly on 100 non-rebreather mask within 15 to 20 minutes . Shortly after his mental status changed he became disoriented and euphoric and continued to be in this state for two more hours . After that period of time his mental status gradually improved and he continued to receive his blood transfusions requiring a total of ten units of packed red blood cells and four units of fresh frozen plasma to reach a hematocrit of 30.0 which remained stable for the duration of his stay . On admission the patient was started on high dose proton pump inhibitors for prophylaxis . On Wednesday 11-25 an esophagogastroduodenoscopy was performed and was significant for the following findings Medium hiatal hernia Barretts esophagus erosion of the gastroesophageal junction granularity erythema and congestion of the antrum in the pre-pyloric region compatible with gastritis . Erosions in the antrum and pre-pyloric region granularity erythema and congestion of the anterior bulb and posterior bulb compatible with duodenitis . It was recommended by Gastroenterology that the patient is to stay off aspirin for at least four to six weeks at discharge to prevent further bleeding . 2. Cardiovascular During transfusion reaction episode the patient had an episode of tachycardia ranging from 134 to 158 for one to two hours . EKG during this episode was taken and showed sinus tachycardia however serial enzymes were significant for CK peaking at 1075 MB peaking at 114 and MB index peaking at 10.8 consistent with myocardial damage . The day following this episode EKG showed loss of R wave progression in anterior leads and Q waves in leads III and AVF consistent with anteroseptal myocardial infarction . The patient s blood pressures remained stable during his stay . He had no episodes of arrhythmia on Telemetry . Cardiology consultation was obtained . The myocardial infarction was attributed to demand ischemia secondary to acute hematocrit drop exacerbated by tachycardia secondary to blood transfusion reaction . Further Cardiologic work-up was suggested as an outpatient at four to six weeks post discharge . The patient was started on Lopressor Lipitor and Lisinopril . 3. After ten units of packed red blood cells and four units",
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"content": " of fresh frozen plasma transfusions the patient s hematocrit remained stable at above 30 . His INR decreased to 1.3 at the time of discharge . He required no blood transfusions for four days prior to discharge . 4. History of pulmonary embolism likely secondary to frequent flying . The need for further anti-coagulation was discussed with the patient s attending Dr. Coleman and it was decided not to continue anti-coagulation due to increased risk of gastrointestinal bleeding . The patient remained symptom free during his stay in the hospital saturating well in room air . 5. Endocrine The patient was restarted on Levothyroxine soon after admission . His hemoglobin A1C was sent and it was pending at the time of discharge . 6. Single mental status change times two hours during episode of blood transfusion reaction . Was most likely due to multiple drugs administered during the episode including Demerol . After this episode the patient s mental status remained clear for the rest of the duration of his stay . 7. Prophylaxis The patient was sent home on proton pump inhibitors . His Helicobacter pylori serology was sent and was pending at the time of discharge . CONDITION AT DISCHARGE Good . DISPOSITION The patient was discharged to home on the following medications . <NOTE_END>",
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"content": "Patient is being sent home on Ecotrin one q.d. Digoxin 0. l25 mg every three days Quinidine 648 mg q.a.m. and 324 mg q.p.m. and q.h.s. Mevacor 20",
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{
"content": " mg p.o. q.d. Carafate one gram p.o. q.i.d. Colace l00 mg p.o. t.i.d. Lasix 80 mg p.o. q.d. Potassium 20 mEq p.o. q.d. and iron supplements . Patient has follow-up with Dr. Merkel and with his private medical doctor . EV956 4659 RISHAN M. MERKEL M.D. BS9 D 01 02 92 Batch 3669 Report F6644X53 T 01 02 92 Dicatated By RAMA R. KOTEOBE M.D. cc 1. <NOTE_END>",
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"content": "The patient is a 48-year-old white man who is 20 days status post orthotopic cardiac transplant who was readmitted for sternal wound infection . He has insulin dependent diabetes mellitus and a history of a dilated cardiomyopathy . He had progressive symptoms of congestive heart failure which led to his evaluation of his cardiac transplant in March of 1991 . Preoperatively he had a severely dilated left ventricle with markedly diminished function . His post transplant course was initially complicated by hyperglycemia and seizure on postoperative day number one . He was however extubted without difficulty and after that did quite well . He had a predischarge biopsy . He felt well at home without fevers chills or rigors . There were no",
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"content": " rashes . He had no chest pain or shortness of breath . When he was seen on 2 3 in the Transplant Clinic his incision was noted to be more erythematous . He was referred to the Surgical Clinic where the wound was opened and the patient was admitted for intravenous antibiotics . <NOTE_END>",
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"content": "Non contributory and unavailable as she is adopted . PHYSICAL EXAMINATION She is an obese",
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"content": " elderly woman in no acute distress . vital signs 158 60 with a heart rate of 85 temperature 99.7 respirations 14 . Her neck showed no JVD . Lungs clear to auscultation . Her abdomen was obese and distended with good bowel sounds large ventral hernia . Colostomy with black stool . She had some mid epigastric tenderness and no rebound . Her heart showed a regular rate and rhythm with an S1-S2 no murmur . Her neurological exam was alert and oriented . She had 5 out of 5 strength bilaterally and her toes were downgoing . She had no evidence of asterixis . Her skin looked very bronze and tan especially in the sun exposed areas . She had no spider angiomata no palmar erythema no xanthomas and no caput medusae . She did not look teric . <NOTE_END>",
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"content": "The patient is a 43-year-old gravida II para II white female referred by Dr. Ca Shuff for evaluation . She was in her usual",
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"content": " state of good health until December when she was seen emergently for treatment of a perforated colon cancer . That area was resected with no evidence of metastatic disease . She has had subsequent CEA&aposs and scans which were negative . A tumor was noted on her vulva which was biopsied and revealed squamous cell carcinoma in situ . <NOTE_END>",
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"content": "Admission sodium of 136 potassium 3.8 chloride 99 bicarbonate 27.3 BUN and creatinine of 13 and 0.6 glucose 86 calcium 9.3 liver function tests notable for an albumin of 2.5 globulin 4.5 . The complete blood count on admission showed a white blood count of 14.5 hematocrit 31.0 hemoglobin 10.3 and platelet count 478 000 . The arterial blood gases on room air were 7.46",
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"content": " 70 41 . The pulmonary function tests revealed an FEV1 of 1.51 FVC 2.72 and FEV1 FVC ratio of 56 . DLCO was 2 or 19 of predicted . <NOTE_END>",
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"content": "The patient was medically managed initially and then underwent on 2013-08-09 coronary artery bypass grafting x2 and a mitral valve annuloplasty with placement of intra-aortic balloon pump . He was transferred to the Intensive Care Unit in relatively stable condition . On postoperative day 1 his balloon pump was weaned and the patient was transferred at 2 units of packed red blood cells . He also began to wean off the ventilator . On postoperative day 1 in the",
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"content": " evening the patient was noted to go into atrial fibrillation for which he was controlled and started on amiodarone after which he converted again to normal sinus rhythm . He was extubated during postoperative day 1 . On postoperative day 2 the patient was noted to be relatively stable . His balloon pump had already been removed and on postoperative day 3 he was transferred to the floor on Lopressor and amiodarone in normal sinus rhythm . On the floor the patient was noted to do extremely well . Physical therapy was consulted and the patient was ambulating extremely well with minimal assistance . On postoperative day 4 he remained afebrile with stable vital signs on Lopressor at 25 mg po bid and an amiodarone dose . His left chest tube was discontinued at this time and his right chest tube was removed the following day on postoperative day 5 . Currently the patient is postoperative day 6 . He remains afebrile with stable vital signs and the patient is ambulating to a level 5 with physical therapy and wishes to be discharged home today . <NOTE_END>",
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"content": "DISCHARGE DISPOSITION To",
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"content": " home . <NOTE_END>",
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"content": "Coronary artery disease status post coronary artery bypass grafting times 4 with LIMA to the LAD saphenous vein graft to OM1 saphenous vein graft to OM2 and saphenous vein graft to the diagonal . Hypertension . Hypercholesterolemia . Status post partial thyroidectomy . Status post hernia repair . Status post left knee surgery . Status post tonsil and adenoid surgery . DISCHARGE MEDICATIONS 1. Atorvastatin 10 mg q.d. 2. Plavix 75 mg q.d. times 3 months . Aspirin 325 mg q.d. Lasix 20 mg q.d. times two weeks . Potassium chloride 20 mEq q.d. times two weeks . Metoprolol 12.5 mg b.i.d. Percocet 1 to 2 tabs q. 4 hours p.r.n . The patient is to be discharged home with visiting nurses . He is to have follow up",
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"content": " in the wound clinic in two weeks and follow up with Dr. Brewster in two to three weeks and follow up with Dr. Rota in 4 weeks . Herbert Jesus Georgia 01835 Dictated By Scott OK Astarita M.D. MEDQUIST36 D 2016-09-14 125227 T 2016-09-14 132805 Job 15604 Signed electronically by DR. Richard Gomez on FRI 2016-09-16 <NOTE_END>",
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"content": "Notable for a sodium of 145 potassium 3.6 BUN",
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"content": " 23 creatinine 1.3 glucose 104 hematocrit 42 white count 8.7 platelet count 235 and a PT of 12.9 seconds . The urinalysis was negative . The Troponin I was less than .4 and the creatine kinase was 114 . Chest x-ray revealed moderate cardiomegaly with no clear interstitial or alveolar pulmonary edema and chronic atelectasis and or scarring at both lung bases . The electrocardiogram revealed normal sinus rhythm with premature atrial complexes and right bundle branch block with left anterior hemiblock and old anterior myocardial infarction . <NOTE_END>",
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"content": "Was discharged on 11 16 2003 in stable condition with the last recorded hematocrit of 31.3 . He was",
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"content": " asked to continue on his Nexium iron and vitamin C and was continued on his other home medications . <NOTE_END>",
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"content": "82 119 60 22 and 99 on room air . Well appearing in no apparent distress . Pupils are equal round and reactive to light . Moist mucous membranes . No JVD . Regular rate and rhythm .', 'Positive tenderness to sternum . Chest was clear to auscultation bilaterally . Abdomen Obese soft . Extremities show no edema 2 dorsalis pedis 1",
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"content": " femoral pulses .'Troponin-T less than 0.01. EKG Sinus 84 normal axis QTc 430 Q s in III and aVF no ST changes as compared to 2017-05-01 EKG . <NOTE_END>",
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"content": "The patient was admitted for intravenous antibiotics and a question of evaluation of circulation to the left great toe and also possible debridement and possibly a toe amputation . The patient had the following radiological studies 08-27-92 left foot film correlation patient consistent with osteomyelitis involving the first digit and possibly the second digit of the left foot . The chest X-ray reveals no evidence of acute disease . The patient had lower extremity arterial non-invasive study",
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"content": " which showed good arterial hemodynamics of the left lower extremity perfusion to the TM level but there was evidence of diabetic small vessel disease and spasm of his digits . The arterial circulation is adequate for healing of his left great toe ulcer noncompressible left thigh and calf pressures highly calcified arterial system . On 09-03-92 patient underwent a left great toe buttontoe amputation under regional ankle block for chronic ulcer and osteomyelitis of the left great toe . The patient tolerated the procedure well . There were no complications during the procedure . There was a small Penrose drain postoperatively that was placed intraoperatively and discontinued on approximately postoperative day number three . The patient was preoperatively treated with about a seven day course of intravenous Unasyn and postoperatively treated for approximately four days of intravenous Unasyn . The patient was discharged home in stable condition on postoperative day number five without any complications . The incision from buttontoe amputation of the left foot healing well without any further complications . FOLLOWUP The patient is to follow up in clinic . <NOTE_END>",
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"content": "ON ADMISSION Temperature 98.8 heart rate 68 blood",
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"content": " pressure 107 82 and oxygen saturation 99 on room air . CHEST Clear to auscultation . HEART Regular rate and rhythm with no murmurs . ABDOMEN Soft mildly distended and tympanic with midepigastric tenderness to palpation and no rebound . The ostomy was pink with minimal fluid in the ostomy bag . It was guaiac negative . EXTREMITIES No signs of edema and the patient had warm and palpable pulses distally . <NOTE_END>",
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"content": "On examination on transfer to the Intensive Care Unit she is febrile with a low grade temperature of 100.1 tachycardic to 110 hypotensive 85 49 tachypneic into the 50 s and 60 s 95 on nonrebreather . In general she is extremely tachypneic difficulty in speaking words . Her heart is regular without murmurs rubs or gallops slightly tachycardic . Her pulmonary examination shows she has bronchial breath sounds with dry crackles at the bases . Abdominal examination was benign . Extremities no clubbing cyanosis or edema . She is alert and following commands . LABORATORY White blood cell count 3.2 hematocrit 26.6 platelets 130 chemistry is 131 potassium 3.0 chloride 105 bicarb 17 BUN 10 creatinine 0.5 glucose 105 . Calcium 7.3 phos 1.8 magnesium 1.5 . She had a gas showing 7.36 31 96 . She had a CT from the 29th of her abdomen and pelvis showing marked increased consolidations at the left lung base and question of new left sided pleural effusion . HOSPITAL COURSE 1. Pulmonary The patient was transferred to the Intensive Care Unit for respiratory distress and febrile hypotension with a question of a new infiltrate on her chest x-ray . The exact etiology of the patient s respiratory distress was presumed to be questionable multifactorial . There was concern about possible pneumonia . Also she had a history of PE and also there was concern about possible lymphangitic spread of her breast CA . Given her fevers and shortness of breath the patient was treated with broad spectrum antibiotics initially started on Ceptaz Levaquin and and Clindamycin . Lab two antibiotics were added considering the patient was thought to be a relatively high risk for PCP Douglas . The patient was initially trialed on BiPAP but the patient was increasingly dyspneic increased respiratory stress and ultimately needed to be intubated on 06-22 . Earlier during her Intensive Care Unit course she underwent bronchoscopy which was sent for cytology and multiple bacterial pathogens all of which were negative . Ultimately her Intensive Care Unit course continued and she began to defervesce and her bacterial studies particulaly from BAL lavage were found to be negative . The patient had multiple antibiotics withdrawn . Clindamycin and was discontinued early in hospital course . Her PCP was thought to be negative . In addition Vancomycin Levaquin were also discontinued . She was later continued on Ceftazidine and Clindamycin for possible gram negative infection and also for possible post obstructive picture that she would be at risk for given her pulmonary anatomy . As the Hubbard Regional Hospital hospital course went on the patient s respiratory did not show mild improvement on the ventilator . She was able to oxygenate originally . Unfortunately her mental status failed to improve despite having been off all sedative medications for several days . Later in her Intensive Care Unit course family meetings took place and given the patient s overall poor prognosis with decreased mental status it was decided that the patient would become CMO . Subsequently she was extubated on 06-28 . The patient continues to actually ventilate well off of the respiratory . However she is CMO and will not be intubated for respiratory distress . 2. Cardiovascular The patient was initially transferred to the Intensive Care Unit thought to be exhibiting septic physiology respiratory distress and hypotensive . She required aggressive intravenous",
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"content": " fluids and later required pressor support with neo-synephrine . Later during her Intensive Care Unit course she was felt to be somewhat overloaded and intravenous fluids were cut back . It was quite difficult weaning her off of neo-synephrine . She was also given stress dose steroids . Later in her hospital course she also had an echocardiogram for question of new ECG findings in her inferior leads . Her echocardiogram however was essentially normal with an ejection fraction of 55 without any gross wall motion abnormalities or valvular pathology . As mentioned above the patient s hemodynamic status was tenuous throughout her hospital course as it was difficult to wean the patient off of neo-synephrine . By 06-28 however the patient had been off of neo-synephrine but at this time as mentioned above the patient was deemed to be CMO per discussion with physicians and her husband health care proxy . 3. Hematology Patient with a history of known malignancy and also a history of pulmonary embolisms from 2012-04-23 . Earlier in her Intensive Care Unit course the team was concerned about possible pulmonary embolisms as a possible source of the patient s respiratory decompensation . However the patient also had brain metastasis and at this point anticoagulation was thought to be a contraindication given risk for hemorrhage into these tumors . She did have lower extremity doppler ultrasounds which were negative . 4. Infectious disease As mentioned above patient initially hypotension febrile and in respiratory distress presumed to be septic source likely pulmonary . Initially the patient was treated with broad spectrum antibiotics including Vancomycin Ceptaz Levaquin Clindamycin and . All of her cultures are negative to date . She was negative for PCP and subsequently was continued and Clindamycin was changed for anaerobic coverage . In addition her Vancomycin and Levaquin were also discontinued . The patient remained afebrile during the majority of her hospital course . By virtue of discussions on 06-28 the patient was deemed to be CMO and all antibiotics were withdrawn at this point . 5. Gastroenterology The patient had an abdominal CT earlier in her Intensive Care Unit course which was essentially negative for an intraabdominal pathology . She was initially supported with tube feeds during her Intensive Care Unit course but at this point the patient is CMO and tube feeds have been subsequently discontinued . DISPOSITION The patient s attending physician was in constant communication with the patient s health care proxy her husband . As her Intensive Care Unit course continued and the patient showed minimal signs of meaningful improvement continued discussions were had with the family about possibly changing code status . Ultimately it was decided by 06-28 that the patient had shown minimal improvement and minimal evidence of improvement status it was decided at this point for the patient to be extubated and to move toward CMO care . Subsequently all antibiotics blood draws and supportive blood pressure medications were withdrawn . Currently she is comfortable with morphine and Ativan prn. Currently plans are in the making for arranging for the patient to have home hospice care . Please see discharge addendum for further developments in the patient s care . DISCHARGE DIAGNOSES Metastatic breast cancer end stage . Respiratory failure unclear etiology presumed secondary to possible pneumonia questionable lymphangitic spread . 3. Sepsis presumed pulmonary source . DISCHARGE CONDITION Grim . <NOTE_END>",
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"content": "Lopressor 100 mg p.o.b.i.d. Lisinopril 10 mg p.o.q.d. Lipitor 10 mg p.o.q.d. Aspirin 81 mg p.o.q.d. Percocet one to two tablets p.o.q. 3-4 h. p.r.n. pain . Colace 100 mg p.o.b.i.d. DISCHARGE PHYSICAL EXAMINATION The patient had a temperature of 98.4 heart rate 72 blood pressure 154 89 respiratory rate 18 and oxygen saturation 90 in room air . He was alert and oriented . His neck was supple without lymphadenopathy . He had",
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"content": " faint bibasilar crackles on lung examination . His heart had a regular rate and rhythm with no murmur rub or gallop . His abdomen was soft nontender and nondistended with a nonerythematous peritoneal dialysis insertion site . Extremities were warm and well perfused . DR . Kemp Julie R. 02 -358 Dictated By Judy Y Carnevale M.D. MEDQUIST36 D 2010-09-18 1942 T 2010-09-22 1110 JOB 34822 Signed electronically by DR. Dalila Talbot on Robert 2010-09-23 <NOTE_END>",
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"content": "Triamcinolone one tablet PO b.i.d. dosage unknown Xanax one tablet PO t.i.d. prn anxiety dosage unknown MS Contin prn . PAST MEDICAL HISTORY Distant peptic ulcer disease thumb and middle finger",
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"content": " lost secondary to lawnmower accident at age five years no peripheral vascular disease . PAST SURGICAL HISTORY The patient is status post partial gastrectomy for peptic ulcer disease in 1965 . <NOTE_END>",
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"content": "The patient was admitted to the hospital and received two units of packed red blood cells for her hematocrit of 26 and had a magnesium repleted . The patient received three days of chemotherapy consisting of 45 mg. of Cisplatin 160 mg. of VP 16 and tolerated chemotherapy resonably well . Serial PTs were obtained and the patient",
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"content": " was noted to have an initial PT of 10.9 on admission despite Coumadin at home . She was given 10 mg. on hospital day 1 and 5 mg. on hospital day 2 and back to 2.5 qhs . The patient &aposs pro time bumped to 19.5 on hospital day 3 and the patient was instructed to continue with 2 1 2 mg. qhs and is to followup with Anticoagulation Clinic in one week for further pro time checks and adjustments . The patient did develop some hypertension during infusion of her VP 16 to the 170 100 range which apparently happened during her prior chemotherapy . The patient was instructed to followup with her internist regarding further evaluation of her hypertension and should be assessed regarding further management as an inpatient or while receiving chemotherapy . <NOTE_END>",
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"content": "1. cerebrovascular accident . The patient suffered some mild weakness which was attributed to stenosis of the distal right internal carotid artery . This was determined by head CT head MRI head MRA carotid noninvasive studies transcranial Dopplers . The possibility of a cardiac origin was evaluated by echocardiogram and Holter monitor . Her echocardiogram curiously showed a normal left ventricular size and systolic function a patent foramen ovale with a trace right to left shunt as determined by bubble study trace MR was present . Previous echoes have shown MVP at the Ona Hospital . Her Holter showed up to 12 beats of SVT but was otherwise unremarkable . The patient had a normal B12 negative syphilis serologies and normal thyroid function during this hospitalization . She was anticoagulated with heparin and after several days Coumadin was started . Her exact Coumadin dose is undetermined at this point however it looks like it will be something around 5 mg a day . Her pro time and PTT have normalized at the time of discharge . She needs to be given 5 mg of Coumadin tonight 5 22 92 . In addition heparin should be started to drip on arrival at 400 units an hour . It is discontinued at the time of transport . The patient has received physical therapy and occupational therapy and her recovery is near complete . During evaluation of her neurologic status it was determined that for several months prior to admission the patient has been too unsteady to ambulate . On our exam she is found to have a significant amount of ataxia especially in the midline and the exact cause of this is unknown . There are multiple possible contributions and this is where her need for careful internal medical evaluation has arisen . At the time we were to",
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"content": " embark on this evaluation the patient &aposs family strongly requested that she be transferred to the Sas General Hospital . What follows is a summary of her medical problems and their possible relationship to her ataxia . Her ataxia is likely due to some cerebellar function though this is not certain . Moreover her MRI did not show any discrete cerebellar lesions . Our leading theory at this point is that her cerebellar dysfunction relates to perineoplastic syndrome relating to her history of breast Ca . As I mentioned above her evaluation was limited by her cardiologic status at the time . While mammogram and CA-15.3 and breast exam are all normal the idea of a perineoplastic syndrome with or without concomitant breast Ca has reared its head . Two possible markers are anti-Hu syndrome and anti-Yo antibody . These tests were sent on the 18th and are pending at the time of discharge . The results can be obtained by paging me Do A. Joasscchird M.D. at 834-364-2251 . I will be happy to furnish the results . The patient has a history of MI in 1989 . Echocardiogram no longer shows wall motion abnormalities . EKG when the patient goes out of left bundle branch block transiently shows an anterolateral Q wave inversion . We would like to discontinue her Isordil to improve upon some orthostatic hypotension but we are not certain whether her heart will tolerate this . Persantine thallium is scheduled at this time but is yet to be performed . The patient has a history of orthostatic hypotension x many years . It has been evaluated in the past without success . During her hospitalization we confirmed the presence of this even when she was hydrated with saline to a fractional excretion of sodium of 2 . Studies of her autonomic system did not document any dysautonomia . Studies of skin galvanic conduction were normal and her RR interval evaluation was not abnormal . This is a chronic problem but may be contributing to her current weakness and inability to walk . Florinef is to be considered however stopping the Isordil is one goal . The patient has a history of bronchiectasis from a childhood pneumonia . In addition there is a distant history of M. kansasaii infection . This has been evaluated by Dr. Screen at Sas General Hospital and probably relates to her lung xray . CT at the Ona Hospital in 1989 showed similar findings . A chest CT was to be performed and may be yielding . A PPD was placed and is to be read on Saturday 4 26th . The left volar forearm has the PPD just proximal to the wrist crease and a candida albicans placed just distal to the antecubital fossa . The patient has a history of deep venous thrombosis in 1990 for which she received 6 months of Coumadin . Dopplers of her lower extremities were negative on this admission . It is doubtful that she has chronic PE but this is one consideration . It is likely that she has pulmonary hypertension from her lung disease and so this is a consideration . The patient had mild hyponatremia during this hospitalization with a sodium as low as 131 . We think this is likely due to an SIADH as she is euvolemic . This can be evaluated further and is not a problem at this time . The patient has glaucoma . Her medications are as listed below . Her ophthalmologist is aware of transfer . His name is Ettrent Can and he can be reached at 678-233-5033 b 549 . DOCTORS DISCHARGE ORDERS Propanolol 5 mg. p.o. t.i.d. hold for SBP less than 110 Isosorbide 5 mg. p.o. t.i.d. hold for SBP less than 110 Colace 100 mg. p.o. b.i.d. Pilocarpine 4 one drop q.i.d. O.D. Pilocarpine 2 one drop b.i.d. O.S. Betasan 0.5 one drop b.i.d. O.D. . Bacitracin ointment one drop O.D. q.h.s. Ciprofloxacin 500 mg. one p.o. b.i.d. x four more days until 5 25 92 for recently discovered siderobacter UTI . Coumadin 5 mg. p.o. q.h.s. She needs her dose on 5 22 92 . Heparin i.v. drip at 400 units per hour on her arrival . In addition the patient requires occupational therapy and physical therapy . <NOTE_END>",
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"content": "Hyperthyroid disease status post radioactive iodine ablation now hypothyroid on Levoxyl History",
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"content": " of pulmonary embolism etiology unknown . It was thought to be induced by frequent flying to California The patient was started on Coumadin five months prior to this admission . 3. Hypercholesterolemia Well controlled on Lipitor . Last total cholesterol was 168 in 2015-08-24 . 4 Paroxysmal atrial fibrillation in the setting of pulmonary embolism . PAST SURGICAL HISTORY 1 Only significant for a right inguinal hernia repair . ALLERGIES Penicillin OUTPATIENT MEDICATIONS Lipitor 10 mg three times a week Aspirin 81 . Propranolol 10 mg three times a day Coumadin 6.25 mg once a day . Levoxyl 100 mEq q. day Ambien p.r.n. Vitamins Vioxx times three weeks . <NOTE_END>",
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"content": "The patient was a 71 year old white female with a history of carcinoid lung cancer who presented for evaluation of a tracheoesophageal fistula . The patient was initially diagnosed in 1978 with atypical small cell carcinoma of the lung and treated with chemotherapy and radiation therapy until 1980 . She did well for approximately twelve years until she was diagnosed with carcinoid cancer of the same right upper lobe . This may have been the initial primary cancer although it is unclear at present . Bronchoscopy at that time showed an endobronchial tumor of the right upper lobe bronchus and it was felt to be unresectable . She underwent four treatments of brachytherapy in March through May of 1993 . She had been doing reasonably well until December of 1993 when she presented with persistent and worsening cough and near strangulation on attempts at eating solids or drinking liquids . A bronchoscopy showed a tracheoesophageal fistula with an opening into the trachea above the carina and no tumor in the right upper lobe . She has been on",
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"content": " total parenteral nutrition and has been nothing by mouth since then . A barium swallow prior to admission showed the presence of a tracheoesophageal fistula with entrance into the right mainstem bronchus below the carina . PAST MEDICAL HISTORY Bronchitis asthma carcinoid cancer no history of coronary artery disease or cerebrovascular accident . PAST SURGICAL HISTORY The patient is status post appendectomy hysterectomy and right salpingo-oophorectomy bladder suspension and a tumor removal from the right neck . <NOTE_END>",
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"content": "The patient is a pleasant elderly female in no acute distress . Her vital signs showed a blood pressure of 126 72 pulse 84 respirations 22 temperature 98.6 . She had a 3 x 4 cm firm nontender right thyroid mass that seemed to be fixed to the trachea . She had no jugular venous distention or bruits . The lungs exhibited right basilar dullness one quarter of the way up . She had no definite S3 . The liver edge was palpable to 6 cm below the right costal margin . Her spleen could not be",
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"content": " palpated . She had 4 edema to the knees bilaterally . <NOTE_END>",
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"content": "The patient was admitted on 07 20 99 for a history of left chest wall pain from postthoracotomy syndrome . The patient developed the syndrome after her thoracic aortic aneurysm repair . The patient failed the conservative therapy and is admitted for",
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"content": " a spinal cord stimulator trial . The patient had a spinal cord stimulator placed on 07 21 99 . She underwent the procedure and tolerated the procedure very well . The spinal cord stimulator was programmed with setting of a rate of 80 power 450 and 4.0 amps . Channel 1 was negative 2 was neutral 3 was neutral 4 was positive . The patient the next two days did not notice any significant change in her pain pattern . The patient was also noted to have a lot of musculoskeletal component of her pain . So an epidural catheter was placed on 07 23 99 . The epidural was placed in the L1-2 region and the catheter was placed in the T7 region using fluoroscope to guide the catheter . Within the next couple of days the patient noticed a significant improvement in her pain pattern . The stabbing sharp pain that she occasionally has on the left chest wall was significantly diminished and she also noticed periods of time when she did not have any of that pain . The epidural catheter had a morphine infusion initially started at 1 mg a day and increased to 3 mg a day in a period of three days . The epidural was discontinued on 07 26 99 and was considered a successful trial . The patient will schedule with the Pain Clinic regarding upcoming epidural pump placement . During her hospitalization the patient was also seen by the Plastic Service . Dr. Falccouette would like to perform an excision and closure flap of her left ischial decubitusin the near future . The patient was discharged in stable conditionand will follow up for 1 sacral decubitus closure and 2 placement of epidural pump in the future . DISCHARGE INSTRUCTIONS The patient will have SMH Service that comes to her home once a day for adressing change . The patient will follow up with Dr. Kayschird to schedule for the epidural pump . The patient will follow up with Dr. Falccouette to schedule for excision and closure of her left ischial sacral decubitus . Dictated By ECI JESCSLAND M.D. OO63 Attending FOMAIRE KOTEKOTEJESCDREWE M.D. RY93 KE526 9219 Batch 37707 Index No. RWRF75BSI D 07 26 99 T 07 26 99 CC <NOTE_END>",
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"content": "PHYSICAL EXAM VITAL SIGNS He was afebrile with stable vital signs HEART Regular rate and rhythm with a 2 out of 6 systolic ejection murmur heard loudest at the apex . LUNGS Clear to auscultation . ABDOMEN Soft nontender",
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"content": " nondistended . EXTREMITIES No cyanosis clubbing or edema . Palpable DP s bilaterally PERTINENT LABS His hematocrit was 44 White count was 8 . Potassium was 3.9 BUN and creatinine was 18 and 0.9 . His troponin was 29.7 <NOTE_END>",
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"content": "Breast cancer status post lumpectomy Mitral commissurectomy . Atrial fibrillation Peripheral vascular disease . Arterial emboli left femoral artery Congestive heart failure",
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"content": " . MEDICATIONS ON TRANSFER Lopressor intravenous q 6 hours . Morphine Sulfate 1 mg intravenous p.r.n. ALLERGIES Penicillin Sulfa and Quinidine . <NOTE_END>",
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"content": "Cefuroxime 1.5 grams intravenously q8h Solu-Medrol 62.5 mg intravenously q8h Ventolin metered dose inhaler 2 puffs",
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{
"content": " PO q.i.d. Pepcid 20 mg intravenously b.i.d. <NOTE_END>",
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"content": "celexa premarin trazodone 6-MP Prednisone Discharge Medications 1. Phenytoin Sodium Extended 100 mg Capsule Sig One 1 Capsule PO TID 3 times a day for 1 months . Disp 90 Capsule s Refills 0 2. Acetaminophen Caff Butalbital 504-61-78 mg Capsule Sig 01-28 Tablets PO Q4-6H every 4 to 6 hours as needed for 1 months . Disp 60 Tablet s Refills 0 3. Citalopram 20 mg Tablet Sig One 1 Tablet PO DAILY Daily . 4. Metoprolol Tartrate 25 mg Tablet Sig One 1 Tablet PO BID 2 times a day",
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"content": " . 5. Hydromorphone 2 mg Tablet Sig 1-2 Tablets PO Q4H every 4 hours as needed for pain . Disp 40 Tablet s Refills 0 6. Docusate Sodium 100 mg Capsule Sig One 1 Capsule PO BID 2 times a day Use while taking narcotics . 7. Phenytoin Sodium Extended 100 mg Capsule Sig One 1 Capsule PO TID 3 times a day . Disp 90 Capsule s Refills 0 Discharge Disposition Extended Care Facility St. Annes Hospital Burlington Discharge Diagnosis Head trauma with subarachnoid hemorrhage C7 fracture Discharge Condition neurologically stable Discharge Instructions Call for severe headache or any other problems . Please take Fioricet as directed for headaches . Please do not drive while on this medication . Please continue to wear your C-collar at all times . Please continue Dilantin as directed for seizure prophylaxis . Followup Instructions Follow up with Dr. Kelley in 4 weeks with head CT call 716 3268 Please also follow-up with Dr. Obrecht of CMED CCU spine in 2 weeks for flexion extension X-rays 228 411-7660 Please follow-up with your PCP N 6-12 months reguading the right thyroid nodule and the bilateral small lung nodules seen on your chest CT . Vernia Diana MD 76-016 Completed by Sonya Ramona NP 80-AKY 2013-04-01 1453 Signed electronically by DR. <NOTE_END>",
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"content": "Tylenol 650 mg p.o. q. 4 -6h p.r.n. headache or pain acyclovir 400 mg p.o. t.i.d. acyclovir topical t.i.d. to be applied to lesion on corner of mouth Peridex 15 ml p.o. b.i.d. Mycelex 1 troche p.o. t.i.d. g-csf 404 mcg subcu q.d. folic acid 1 mg p.o. q.d. lorazepam 1-2 mg p.o. q. 4 -6h p.r.n. nausea and vomiting Miracle Cream topical q.d. p.r.n. perianal irritation Eucerin Cream topical b.i.d. Zantac 150 mg p.o. b.i.d. Restoril 15 -30 mg p.o. q. h.s. p.r.n. insomnia multivitamin 1 tablet p.o. q.d. viscous lidocaine",
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"content": " 15 ml p.o. q. 3h can be applied to corner of mouth or lips p.r.n. pain control . CONDITION UPON DISCHARGE Stable . FOLLOWUP Follow up appointment with Die Anoort and Tomedankell Care on 11 18 00 at 930 a.m. one day after discharge . The patient knows to go to Sper Medical Center every day for line care blood draws and monitoring . Dictated By CONRELLIE KOTERUDES M.D. VJ31 Attending SUOT CARE M.D. OB89 RL958 5760 Batch 24769 Index No. GFNC2Z5N8Q D 11 22 00 T 11 22 00 CC 1. <NOTE_END>",
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"content": "By systems Respiratory . After receiving brief blow by oxygen in the delivery room the patient had no further episodes of ventilatory assistance required with good respiratory rate consistently . The patient was never placed on caffeine . He is stable in room air at this time . Cardiovascular . No active issues . No history of hypotension . On no medications at this time . Notably with respect to apnea and bradycardia of prematurity the patient has reached 5 days without significant apneic or bradycardic spells as of the time of discharge . Fluids electrolytes and nutrition . The patient reached full volume feeds by day of life 6 and had calories increased to maximum of 26 kilocalories per ounce of Similac special care until 2014-12-03 at which point this was weaned to 24 kilocalories per ounce of straight Similac . This is the baby s discharge feedings and he is p.o. ad lib with a minimum of 130 ml kg day the patient has taken on an average greater than 150 ml kg day ad lib over each of the past 5 days . GI . The patient with peak bilirubin of 6.5 on day of life 3 . No phototherapy was required . Hematology Infectious Disease . The patient s hematocrit at delivery was 48 with a white count of 11.2 and platelets of 301 000 . Initial differential was 35 polys and zero bands not suspicious for infectious condition . The patient was initially treated with 48 hours of ampicillin and gentamicin until blood cultures were negative . The infant has had no antibiotics since that time . Neurology . No issues . Sensory . Hearing screen",
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"content": " was performed with automated auditory brainstem responses and was normal on 2014-11-24 . Ophthalmology . The patient did not qualify for routine ophthalmology exams due to his gestational age at birth . <NOTE_END>",
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"content": "Significant for sodium 140 potassium 3 BUN 35 creatinine 3.6 liver function tests within normal limits calcium 6.6 albumin 2 magnesium1.4 PT 14 white count 30.1 with 77 polys 13 bands 5 lymphs and 5 monos . Urine sodium is 75 urine creatinine 143 urine osmose 392 .",
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"content": " Pleural fluid pH is 7.29 glucose 91 total protein3.1 LDH 296 70 white blood cells 50 red blood cells . HOSPITAL COURSE 1. Colitis . The patient has a history of ischemic bowel status post SMA Percutaneous Transluminal Coronary Angioplasty with recent admission for gram negative rod urosepsis complicated by C. difficile colitis . The patient received a full course of Flagyl and was C. difficile toxin negative times three prior to transfer . He now returns with fever rising white count diarrhea and dehydration . Initially treated with intravenous ceftizoxime gentamicin and Flagyl for presumed sepsis either with urine or bowel source . He was also started on p.o. Vancomycin . Blood cultures and urine cultures came back negative . Stool for C. difficile returned positive . The diagnosis therefore was relapsed C. difficile colitis . Intravenous antibiotics were discontinued and the patient was continued on p.o. Vancomycin . He improved clinically with defervescence decreased white blood cell count to 10 000 with resolution of left shift and some decrease in abdominal distention on exam . An abdominal CAT scan revealed thickened bowel wall and thumb printing primarily involving the cecum and right colon greater than the left consistent with C. difficile colitis . The diagnosis of recurrent bowel ischemia however was not ruled out and this will continue to be a concern in the future . The patient was initially n.p.o. and was then advanced to clear liquids which he tolerated . He will be advanced to soft solids prior to discharge . 2. Azotemia . The patient has chronic renal insufficiency with baseline creatinine 1.8-2 . Creatinine had risen to 4.3 on admission presumed secondary to sepsis and dehydration . With intravenous hydration the BUN and creatinine fell to 12 1.9 which is within normal limits for this patient . The abdominal CAT scan showed no evidence of hydronephrosis orrenal abscess . 3. Mental status . The patient was alert and oriented throughout the admission however by personality he is somewhat cantankerous and demanding of the nurses . He was written for Haldol 1 mg p.o.b.i.d. p.r.n. to help with this problem . DISCHARGE DISPOSITION Medications on transfer include multivitamin 1 tablet p.o. q.d. Pepcid 20 mg p.o. b.i.d. Ventolin inhaler two puffs q.i.d. Vancomycin 125 mg p.o. q.i.d. times seven days calcium carbonate 1250 mg p.o. b.i.d. Lotrimin cream to groin b.i.d. p.r.n. O2 at four liters per minute and Haldol 1 mg p.o. b.i.d. p.r.n. Dictated By CA NA SHUFF M.D. SO92 VX072 9578 TRANGCA CHIRDSTEN M.D. ZO84 D 07 17 91 T 07 17 91 Batch <NOTE_END>",
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"content": "Father died at age 56 of coronary artery disease . Mother died at age 68 of pancreatic carcinoma . Brother has coronary",
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"content": " artery disease . There is no family history of hematologic problems . LABORATORY Laboratory studies on admission were notable for a sodium of 131 potassium 6.2 BUN 111 creatinine 3.9 white blood cell count 23 hematocrit 27 with 2 schistocytes and 2 spherocytes on the smear platelet count 92 and LDH 496 . <NOTE_END>",
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"content": "ON ADMISSION Birth weight 1455 grams 50th percentile head circumference 29.25 cm 50th percentile length 41.5 cm 50th percentile . Nondysmorphic with overall appearance consistent with gestational age . Anterior fontanel soft open flat red reflex present bilaterally palate intact . Intermittent grunting moderate intercostal retractions diminished air entry regular rate and rhythm without murmur 2 femoral pulses . Abdomen benign with no hepatosplenomegaly or masses . No external female genitalia . Normal back and extremities",
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"content": " with stable hips appropriate tone skin pink with fair perfusion . HOSPITAL COURSE 1. Pulmonary On admission the infant required CPAP 6 cm of water 30 oxygen . Initial capillary blood gas was pH 7.29 CO2 47 . Infant was intubated on day of life two for increased respiratory distress and received one dose of surfactant . Infant was extubated on day of life four to CPAP and transitioned to room air on day of life six . The infant has remained in room air throughout the hospitalization . Caffeine citrate was started on day of life six and was discontinued on 05-23 day of life 18 . The last apnea and bradycardia was on 06-10 . 2. Cardiovascular The infant has remained hemodynamically stable throughout this hospitalization no murmur . Heart rate 150 to 160 mean blood pressure 40 to 54 . 3. Fluid electrolytes and nutrition Infant was initially nothing by mouth receiving 80 cc per kilogram per day of D10W intravenously . Infant was started on enteral feedings on day of life four and advanced to full volume feedings of 150 cc per kilogram per day by day of life seven . During feeding advancement infant was given parenteral nutrition and intralipids . The infant tolerated feeding advancement without difficulty . Infant was advanced to maximum caloric density of breast milk or premature Enfamil 26 calories per ounce with ProMod by day of life 11 . Infant is currently on breast milk or Enfamil 24 calories per ounce po minimum 140 cc per kilogram per day . The most recent weight is 2525 g. Head circumference 24.5 cm length 45.5 cm . The most recent electrolytes on day of life five were sodium 145 chloride 115 potassium 4 TCO2 of 21 . On day of life 25 calcium 10.1 phosphorus 6.9 alkaline phosphatase 341 . 4. Gastrointestinal Infant was started on double phototherapy on day of life two for a maximum bilirubin level of 8.1 with a direct of 0.3 . Infant decreased to single phototherapy and phototherapy was discontinued on day of life six . Rebound bilirubin level on day of life seven was 5.3 with a direct of 0.3 . 5. Hematology The infant did not receive any blood transfusions this hospitalization . The most recent hematocrit on day of life two was 47 . CBC on admission white blood cell count 8.9 hematocrit 47 platelets 243 000 6 neutrophils 0 bands . Repeat CBC on day of life two showed a white blood cell count of 8.4 platelets 95 41 neutrophils 0 bands . Repeat platelet count on day of life three was 229 . 6. Infectious disease The infant received 48 hours of ampicillin and gentamicin for rule out sepsis . Blood cultures remained negative to date . Infant has not had any issues with sepsis this hospitalization . 7. Neurology Head ultrasound on day of life seven showed no intraventricular hemorrhage . A repeat head ultrasound on day of life 33 06-07 showed a slight increase of echogenicity in the caudothalamic groove which may represent tiny bilateral germinal matrix hemorrhages no periventricular leukomalacia . A repeat head ultrasound is recommended in one month . Normal neurological examination . Sensory hearing screening was performed with automated auditory brain stem responses . Infant passed both ears . Ophthalmology eyes examined most recently on 05-30 revealing immaturity of the retinal vessels but no ROP as of yet . A follow up examination should be scheduled for the week of 06-20 . Ophthalmologist is Dr. Cruea Franklin . 8. Psycho social Parents involved . Triplet number one is still in the Neonatal Intensive Care Unit and triplet number three is home with family and there is also a 2 year-old sibling . CONDITION ON DISCHARGE Stable on room air . DISCHARGE DISPOSITION Home with parents . NAME OF PRIMARY PEDIATRICIAN Dr. Janetta Burmaster phone number 262 892 0330 fax 491-6171 . CARE AND RECOMMENDATIONS Feedings breast milk or Enfamil 24 calories per ounce breast milk mixed with 4 calories per ounce of Enfamil powder minimum of 140 cc per kilogram per day po . <NOTE_END>",
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"content": "The patient is an 83 year-old male with a history of diabetes steroid-treated polymyalgia rheumatica hypertension benign prostatic hypertrophy and high cholesterol without presented to the hospital for lower extremity angiograph however that was deferred due to new onset renal failure . 1. RENAL FAILURE The patient was initially thought",
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"content": " to be prerenal and his renal status improved after hydration and increased oral intake . He did have a magnetic resonance angiography of his kidneys which showed mild right-sided renal artery stenosis . His renal function fluctuated throughout his hospital stay and when he was in the Medical Intensive Care Unit he did have decreased urine output in the setting of cardiogenic shock . CARDIOVASCULAR The patient with severe peripheral vascular disease . During his hospital stay he developed some nonsustained ventricular tachycardia . He also became hypotensive on 07-02 in the setting of infection . The patient had a central line placed and went into sustained ventricular tachycardia that was treated with lidocaine . After being treated with lidocaine the patient became apneic requiring intubation and transfer to the Coronary Care Unit . His nonsustained ventricular tachycardia was treated with a lidocaine drip . It was found that he had elevated troponins and likely an ischemic event on the 07-02 . A repeat echocardiogram showed a decreased ejection fraction from prior . He had a cardiac catheterization which revealed 3-vessel disease . Cardiothoracic Surgery was consulted and due to the patient s acute illness they wanted to re-evaluate after the patient was extubated . The patient continued to have intermittent episodes of ventricular tachycardia . He was continued on lidocaine and eventually changed over to amiodarone . He was noted to be cardiogenic shock requiring pressors . Of note he likely suffered a second ischemic event during his Coronary Care Unit stay . The patient did have a Swan-Ganz catheter in place and had a low cardiac output . The patient s family eventually decided to withdraw care and the patient was extubated and passed away on 2009-07-12 . 2. INFECTIOUS DISEASE The patient was initially treated with levofloxacin for a left lower lobe infiltrate and a urinary tract infection . He then developed positive blood cultures with Staphylococcus aureus sensitive to levofloxacin and that was continued . When the patient became hypotensive and required intubation and pressors his antibiotics were broadened and he was put on stress-dose steroids . He was found to have bilateral Staphylococcus pneumonia . 3. PULMONARY The patient required intubation in the setting of hypotension and ventricular tachycardia . He was actually extubated on 07-09 but then reintubated one hour later due to hypoxia . He was also found to have a bilateral Staphylococcus pneumonia . DISCHARGE DISPOSITION On 07-12 after and extensive family meeting the family decided to extubate the patient and make him comfortable and he passed away at 520 on 2009-07-12 . Hattie L Breaux M.D. 33 -679 Dictated By Larry W. Nagy M.D. MEDQUIST36 D 2009-12 -03 0918 T 2009-12-08 1047 JOB 32151 Signed electronically by DR. <NOTE_END>",
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"content": "By systems Respiratory Pocasset was admitted to the newborn intensive care unit with mild respiratory distress . Chest x-ray revealed a left pneumothorax which resolved on its own without intervention . The infant has remained in room air throughout her hospital course with occasional apnea and bradycardia episodes the last being documented on 2020-01-14 . Cardiovascular Attleboro has been stable throughout her newborn intensive care course without issue . Fluids and electrolytes Birth weight was 1515 grams . She was initially started on 80 cc per kilo per day of D10W . Enteral feedings were initiated on day of life 1 . Full enteral feedings were achieved by day of life 7 . The infant had a course of heme positive stools with grossly bloody streaks and mucus felt to be protein allergy . The infant is now receiving breast milk with Nutramigen powder concentrate to 24 calorie . Stools have been negative to trace positive and abdominal exam is reassuring . Discharge weight is 2040 gm the head circumference is 32 cm and the length is 46 cm. . GI",
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"content": " Peak bilirubin was on day of life 2 of 4.8 0.3 . Hematology Hematocrit on admission was 41 . The infant did not require any blood transfusions during this hospital course . Infectious disease CBC and blood culture were obtained on admission . White count was 4.8 7 polys zero bands platelet count of 316 000 . ANC at that time was 336 . A 24 hour CBC was obtained . White blood cell count was 5.1 22 polys zero bands with a hematocrit of 39.3 and platelets of 313 000 . The infant received 48 hours of ampicillin and gentamicin which were discontinued with a negative blood culture . Neurology The infant has been appropriate for gestational age . Sensory Audiology hearing screen was performed with automated auditory brainstem responses and the infant passed on both ears . CONDITION ON DISCHARGE Stable . DISCHARGE DISPOSITION To home . PRIMARY PEDIATRICIAN Dr. Donald Carrion telephone number 861 840 7928 . CARE RECOMMENDATIONS Continue breast milk 24 calories of Nutramigen for concentration . Medications The infant is receiving Fer-in-Phillip supplementation of 0.15 ml p.o. once daily . Car seat position screening was performed for screening and the infant passed . State newborn screens have been sent per protocol most recently on 01-11 and have been within normal limits . Immunizations received Hepatitis B vaccine on 2020-01-19 . Immunizations recommended Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following 3 criteria Born at less than 32 weeks born between 32 and 35 weeks with 2 of the following Daycare during RSV season a smoker in the household neuromuscular disease airway abnormalities or school age sibling or 3 with chronic lung disease . 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 24 months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers . DISCHARGE DIAGNOSES Premature twin 1 born at 32 and 5 7 weeks . Rule out sepsis with antibiotics . Respiratory distress with left pneumothorax resolved . Mild hyperbilirubinemia . Mild apnea and bradycardia of prematurity resolved . Possible milk proteine allergy FOLLOW UP Appointments recommended A hip ultrasound due to breech breech presentation of twins . Tai Pamela Christopher Oklahoma 05158 Dictated By John T Hall M.D. MEDQUIST36 D 2020-01-19 025247 T 2020-01-19 091210 Job 76780 Signed electronically by DR. Charles TRAN on MON 2020-01-20 822 AM <NOTE_END>",
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"content": "Significant for glaucoma right knee",
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{
"content": " arthroscopic surgery in 1988 appendectomy dilation and curettage times two and a hiatus hernia <NOTE_END>",
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"content": "Non contributory and unavailable as she is adopted . PHYSICAL EXAMINATION She is an obese elderly woman in no acute distress . vital signs 158 60 with a heart rate of 85 temperature 99.7 respirations 14 . Her neck showed no JVD . Lungs clear to auscultation . Her abdomen was obese and distended with good bowel sounds large ventral hernia . Colostomy with black stool . She had some mid epigastric tenderness and no rebound . Her heart showed a regular rate and rhythm with an S1-S2 no murmur . Her neurological exam was alert and oriented . She had 5 out of 5 strength bilaterally and her toes were downgoing . She had no evidence of asterixis . Her skin looked very bronze and tan especially in the sun exposed areas . She had no spider angiomata",
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"content": " no palmar erythema no xanthomas and no caput medusae . She did not look teric . <NOTE_END>",
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"content": "Factor 8 deficiency . Subgaleal hemorrhage resolved . Small occipital subdural hemorrhage resolved Reviewed By Mavis W. Mobley M.D. 21 -114 Dictated By William A. Hunter M.D. MEDQUIST36 D 2012-05-18 1358 T",
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"content": " 2012-05-18 1422 JOB 93716 Signed electronically by DR. George Sherwood on MON 2012-05-21 1157 AM <NOTE_END>",
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{
"content": "Sodium 140 potassium 4.0 chloride 104 CO2 28 BUN 14 creatinine 1.1 glucose 243 . Cholesterol 197 triglycerides 118 HDL 31 LDL 142 total protein",
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{
"content": " 6.2 bilirubin 1.0 alkaline phosphatase 72 SGOT 23 . Hematocrit on admission was 43 with a white blood count of 6600 . MCV was 85 . <NOTE_END>",
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{
"content": "Morphine prn . Ativan prn . Tylenol prn . Albuterol and Atrovent nebs",
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{
"content": " prn . Rice S.F. Thrash M.D. 15-419 Dictated By Brett E.X. Im M.D. MEDQUIST36 D 2012-06-29 0115 T 2012-06-29 0547 JOB 44693 Signed electronically by DR. Vicki Baker on TUE 2012-07-03 823 AM <NOTE_END>",
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"content": "The patient is an 82 year-old right handed",
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{
"content": " gentleman who has a past medical history of hypertension and tobacco use presented to the emergency room with acute change in mental status . He was well until the evening prior to presentation to the emergency room when he complained of headache across the forehead . On the day of presentation he was then found by his daughter lying on his bed groaning being relatively unresponsive and unable to speak . The family reported one episode of vomiting at home . <NOTE_END>",
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"content": "The past medical history",
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"content": " was significant for left shoulder surgery in 2014-03-06 for repair of a minor rotator cuff tear and removal of osteophytes Otherwise the past medical history was insignificant . MEDICATIONS ON ADMISSION The patient was on no medications . <NOTE_END>",
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"content": "Spironolactone 50 mg p.o. b.i.d. 2 Advil p.r.n. 3 Topical steroids for eczema p.r.n. ALLERGIES The",
"role": "user"
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{
"content": " patient had no known drug allergies . <NOTE_END>",
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[
{
"content": "Aspiration pneumonia bilateral multiple strokes chronic atrial",
"role": "user"
},
{
"content": " fibrillation prostatic hypertrophy with gross hematuria . <NOTE_END>",
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[
{
"content": "Tylenol 650 mg p.o. q. 4 -6h p.r.n. headache or pain acyclovir 400 mg p.o. t.i.d. acyclovir topical t.i.d. to be applied to lesion on corner of mouth Peridex 15 ml p.o. b.i.d. Mycelex 1 troche p.o. t.i.d. g-csf 404 mcg subcu q.d. folic acid 1 mg p.o. q.d. lorazepam 1-2 mg p.o. q. 4 -6h p.r.n. nausea and vomiting Miracle Cream topical q.d. p.r.n. perianal irritation Eucerin Cream topical b.i.d. Zantac 150 mg p.o. b.i.d. Restoril 15 -30 mg p.o. q. h.s. p.r.n. insomnia multivitamin 1 tablet p.o. q.d. viscous lidocaine 15 ml p.o. q. 3h can be applied to corner of mouth or lips p.r.n. pain control . CONDITION UPON DISCHARGE Stable . FOLLOWUP Follow up appointment with Die Anoort and Tomedankell Care on 11 18 00 at 930 a.m. one day after discharge . The patient knows to go to Sper Medical Center every day for line care blood draws and monitoring . Dictated By CONRELLIE KOTERUDES M.D. VJ31 Attending SUOT CARE",
"role": "user"
},
{
"content": " M.D. OB89 RL958 5760 Batch 24769 Index No. GFNC2Z5N8Q D 11 22 00 T 11 22 00 CC 1. <NOTE_END>",
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{
"content": "Aspirin 325 mgs PO q.d. Prilosec 20 mgs PO q.d. Azmacort 2 puffs q.i.d. PRN Atrovent 2 puffs q.i.d. PRN heparin 5 000 units subcu. b.i.d. Digoxin 0.125 mgs PO q.d. Wellbutrin 37.5 mgs PO b.i.d. Kaopectate PRN Betoptic 0.25 OU q.d. Ritalin 10 mgs",
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"content": " PO q.a.m. and at noon time Norvasc 2.5 mgs PO q.d. The patient reported disorientation with Ambien and Halcyon . <NOTE_END>",
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[
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"content": "1 Cardiovascular The patient was admitted for rule out myocardial infarction . She remained on telemetry for greater than 48 hours which demonstrated no dysrhythmia during this time . The patient underwent an echocardiogram which demonstrated a preserved ejection fraction with left ventricular hypertrophy and no significant valvular abnormalities . The patient was maintained on her aspirin and Lasix . The patient &aposs Diltiazem was stopped due to her increased blood pressure and was started on Labetalol which was gradually titrated up to a target blood pressure of 160-170 systolic in her right arm . The patient also underwent an Adenosine MIBI stress test which showed only mild lateral ischemia . At this time the patient &aposs presyncopal symptoms were not felt to be secondary to a cardiovascular etiology . 2 Neurological vascular The discrepancy in the patient &aposs pulses and blood pressure was felt to be consistent with a subclavian artery stenosis . The patient underwent MRI MRA of the head neck and upper chest which demonstrated a proximal left subclavian artery stenosis proximal to the take off of the left vertebral artery . The left vertebral artery had a decreased flow consistent with either native vessel disease or some degree of retrograde flow with subclavian steal phenomenon . The patient had patent carotids bilaterally on her neck MRA . MRI of the head demonstrated a small vessel disease and was likely an old right cerebellar infarct . The patient underwent non-invasive carotid ultrasounds which demonstrated no significant carotid disease . The patient was also noted to have antegrade flow in both of her vertebral arteries bilaterally . The results of these studies suggested that the patient &aposs symptoms were not due to subclavian steal phenomenon and therefore it was decided that the patient would not go further to angio and or surgical or percutaneous intervention .",
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"content": " A Neurology consult was obtained and it was felt that the most valuable intervention that could be done for the patient &aposs intervascular disease would be adequate control of her blood pressure . 3 Orthopedic The patient suffered a fall at home with her initial event . Outside hip films were obtained but were not available for view . Repeat hip films demonstrated a right sided pubic rami fracture likely new . An Orthopedics consult was obtained and the patient was encouraged to weight bear as tolerated with Physical Therapy assistance . A bone scan was also obtained to rule out an occult hip fracture which was negative . At the time of this dictation the patient was able to bear weight with the assistance of Physical Therapy and a walker .Plan <NOTE_END>",
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"content": "The patient is a 43-year-old gravida II para II white female referred by Dr. Ca Shuff for evaluation . She was in her usual state of good health until December when she was seen emergently for treatment of a perforated colon",
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{
"content": " cancer . That area was resected with no evidence of metastatic disease . She has had subsequent CEA&aposs and scans which were negative . A tumor was noted on her vulva which was biopsied and revealed squamous cell carcinoma in situ . <NOTE_END>",
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