test01_text_only.csv

row_id,text
0,"1 g/dL
   48 mg/dL
   2.8 mg/dL
   31 mEq/L
   4.7 mEq/L
   58 mg/dL
   100 mEq/L
   134 mEq/L
   28.6 %
   4.7 K/uL
        [image002.jpg]
                             [**2200-1-15**]  03:06 AM
   WBC
   4.7
   Hct
   28.6
   Plt
   220
   Cr
   2.8
   TropT
   0.14
   Glucose
   48
   Other labs: PT / PTT / INR:14.3/39.1/1.2, CK / CKMB /
   Troponin-T:65//0.14, ALT / AST:13/27, Alk Phos / T Bili:160/0.6, Lactic
   Acid:1.3 mmol/L, Albumin:3.1 g/dL, Ca++:12.5 mg/dL, Mg++:2.2 mg/dL,
   PO4:3.9 mg/dL
   Imaging: [**1-14**] CXR: IMPRESSION: No acute cardiopulmonary abnormality.
   [**1-15**] Head CT: No acute intercranial Hemorrhage
   Microbiology: BCx UCx pending
   Assessment and Plan
 BRADYCARDIA
 .H/O RESPIRATORY FAILURE, CHRONIC
 DIABETES MELLITUS (DM), TYPE II
 HYPERTENSION, MALIGNANT (HYPERTENSIVE CRISIS, HYPERTENSIVE EMERGENCY)
 HYPOGLYCEMIA
   ICU Care
   Nutrition:
   Glycemic Control:  Regular insulin sliding scale
   Lines:
   20 Gauge - [**2200-1-14**] 10:36 PM
   22 Gauge - [**2200-1-14**] 10:37 PM
   Prophylaxis:
   DVT: SQ UF Heparin(Systemic anticoagulation: None)
   Stress ulcer:
   VAP:
   Comments:
   Communication:  Comments:
   Code status: Full code
   Disposition:ICU"
1,"Chief Complaint:
   24 Hour Events:
 URINE CULTURE - At [**2200-1-15**] 01:30 AM
   -Blood sugar stable overnight
   -Troponin elevated but stable at 0.14
   - Bradycardic to high 30s low 40s after Metoprolol administration
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Dextrose 50% - [**2200-1-15**] 03:30 AM
   Other medications:
   Changes to medical and family history:
   Review of systems is unchanged from admission except as noted below
   Review of systems:
   Flowsheet Data as of  [**2200-1-15**] 07:20 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                               Since 12 AM
   Tmax: 37."
2,"6
C (99.6
   Tcurrent: 37
C (98.6
   HR: 44 (44 - 95) bpm
   BP: 144/50(76) {123/50(71) - 190/74(95)} mmHg
   RR: 14 (11 - 18) insp/min
   SpO2: 100%
   Heart rhythm: SB (Sinus Bradycardia)
   Wgt (current): 48 kg (admission): 48 kg
   Height: 72 Inch
             Total In:
                                                                    178 mL
                                                                  1,147 mL
   PO:
             TF:
   IVF:
                                                                    178 mL
                                                                  1,097 mL
   Blood products:
   Total out:
                                                                      0 mL
                                                                    575 mL
   Urine:
   575 mL
   NG:
   Stool:
   Drains:
   Balance:
                                                                    178 mL
                                                                    572 mL
   Respiratory support
   O2 Delivery Device: Nasal cannula
   SpO2: 100%
   ABG: ///31/
   Physical Examination
   Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial
   pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:
   Not assessed)
   Skin:  Not assessed
   Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:
   Not assessed
   Labs / Radiology
   220 K/uL
   10."
3,"Admission Date:  [**2200-1-14**]              Discharge Date:   [**2200-1-24**]

Date of Birth:  [**2120-4-7**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypoglycemia, hypertensive urgency

Major Surgical or Invasive Procedure:
None

History of Present Illness:
79 y/o F with PMHx of type II DM, CRI & HTN who presented to
clinic today for follow up of elevated creatinine and was found
to be profoundly hypoglycemic with BS of 20 that did not improve
with po trial. Per family, pt has not been taking much po for
the last few days and has been complaining of fatigue."
4,"She has a
long history of poor med compliance and has been living with her
daugter for the last 2 months who has been managing her
medications. Pt was seen in clinic on [**2200-1-2**] and was noted to
be increasingly hypertensive, for which Lisinopril was increased
to 40mg daily. Follow up labs were notable for a progressive
rise in creatinine from 1.5 to 2.9. During this time, Lisinopril
was stopped and Glipizide was increased to 15mg [**Hospital1 **]. Pt denies
having low BS at home and reports decreased appetite and dark
urine. Per family, there were no significant changes in MS prior
to presenting to clinic today."
5,"[**Name (NI) 32883**] vitamin D and PTHrP are pending at the time of
discharge. She will continue receiving saline infusions at rehab
to ensure adequate hydration. The importance of adequate oral
hydration was nonetheless reinforced with the patient and her
family. She will follow up with endocrinology clinic as an
outpatient.
.
#Acute on Chronic Renal Failure - Creatinine improved from 3.0
to 1.9 with volume repletion. A new baseline was attributed to
the progression of nephropathy as evidenced by diffuse
echogenicity in both kidneys on ultrasound.
.
#Acute uncomplicated cystitis - Treated with ciprofloxacin for 7
days.
.
#DMII - Oral hypoglycemic agents were held initially in the
setting of hypoglycemia and were not restarted due to renal
insufficiency."
6,"She was started on basal and sliding scale
insulin, as above.
.
#Thyroid nodule - Chest CT incidentally discovered a
heterogeneous enlarged thyroid with asymmetric enlargement of
the right lobe and coarse calcifications in both lobes. Thyroid
ultrasound revealed multinodular goiter with the largest nodule
in the lower pole of the right lobe measuring 4.1 x 2.4 x 3.9
cm. The patient may benefit from outpatient FNA.


Medications on Admission:
AMLODIPINE 10 mg daily
GLIPIZIDE 15 mg Tablet [**Hospital1 **]
HYDRALAZINE 50mg q6hrs
PRAVASTATIN 40 mg daily
TRIAMTERENE-HYDROCHLOROTHIAZIDE 37.5 mg-25 mg daily



Discharge Medications:
1. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO at bedtime:
hold for sbp<100."
7,"Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1186**] - [**Location (un) 538**]

Discharge Diagnosis:
Primary
1. Hypoglycemia
2. Hypertensive urgency
3. Hypercalcemia
4. Acute on chronic renal insufficiency
5. Acute uncomplicated cystitis
6. Diabetes mellitus type II

Secondary
1. Thyroid nodule
2. Anemia of chronic disease


Discharge Condition:
Asymptomatic with stable vital signs.


Discharge Instructions:
You were admitted to the hospital with very low blood sugar,
possibly because your kidneys weren't properly clearing your
diabetes medication from the blood. We have therefore
discontinued GLIPIZIDE. In its place, we recommend that you
begin taking insulin shots to help control your diabetes.

You were also found to have high levels of calcium in the blood."
8,"No prior studies available.
IMPRESSION: Probable degenerative changes as discussed above. If

hyperparathyroid adenoma is considered as a cause of
hypercalcemia, suggest nuclear medicine parathyroid scanning.
.

Brief Hospital Course:
#Hypoglycemia - Thought to be due to sulfonylurea therapy in the
setting of acute on chronic renal insufficiency. Oral
hypoglycemics were held. Corrected with dextrose, glucagon, and
octeotide in the MICU. Patient tolerated the eventual
reintroduction of basal and sliding scale insulin therapy.
.
#Hypertensive Urgency - Remained asymptomatic. Lisinopril had
been discontinued one week prior in the setting of acute on
chronic renal insufficiency. Initially treated with a
betablocker, norvasc, and hydralazine but the former was
subsequently held due to bradycardia."
9,"9 cm. Both lobes are heterogeneous with
multiple
nodules. Again, nodules range from hyper to hypoechoic and some
nodules
contains cystic areas. The largest nodule is again located in
the lower pole of the right lobe, a solid nodule measuring 4.1 x
2.4 x 3.9 cm. On the left, the largest (spongy) nodule measures
1.8 x 2.1 x 1 cm. In the isthmus, a mixed cystic and solid
nodule measures 1.2 x 0.9 x 1.2 cm.
IMPRESSION: Multinodular goiter. The gland and nodules have
enlarged since
the prior study of [**2191**], although technical differences make
direct comparison difficult."
10,"Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The right
ventricular free wall is hypertrophied. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-20**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion."
11,".
[**2200-1-18**] CHEST CT W/O CONTRAST
IMPRESSION:
1. No evidence of pulmonary nodule or mass.
2. Cardiomegaly, with coronary artery calcification, as
described above.
3. Heterogeneous, enlarged thyroid, with calcifications as
described above. The patient has not had a thyroid ultrasound at
this institution since [**2191**], and if there has not been a recent
evaluation, repeat assessment is recommended.
.
[**2200-1-20**] THYROID U/S
THYROID ULTRASOUND: Evaluation is somewhat limited due to
patient
positioning. The right lobe measures 7.2 x 4.8 x 3.2 cm. The
left lobe
measures 4.8 x 3.22 x 2."
12,"7* Phos-4.0 Mg-2.0
[**2200-1-17**] 08:40AM BLOOD Calcium-11.0* Phos-3.5 Mg-1.8
[**2200-1-17**] 01:00AM BLOOD Albumin-2.8* Calcium-11.5* Phos-3.7
Mg-1.9
[**2200-1-16**] 06:15AM BLOOD calTIBC-259* Ferritn-248* TRF-199*
[**2200-1-16**] 03:58PM BLOOD PTH-12*
[**2200-1-17**] 01:40AM BLOOD freeCa-1.51*

[**1-15**] TTE
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal."
13,"SBPs came down to 170s
prior to transfer.
.
On arrival to the ICU, pt was responding slowly but denying any
chest pain, shortness of breath, abdominal pain, nausea,
headache, fevers, chills and feels generally improved since
arrival to the ED.
.
Review of sytems:
+ recent wt loss of 15 lbs, decreased appetite and dark yellow
urine
.
Denies fever, chills, headache, sinus tenderness, rhinorrhea or
congestion, shortness of breath, chest pain, nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.


Past Medical History:
DM II
HTN
Thyroid Nodule
Anemia
Bilateral Cataracts
s/p TAH"
14,"Social History:
The patient currently lives with her daughter [**Name (NI) **] in [**Name (NI) 2268**].
The patient is reported at baseline to be completely independent
in all ADL, she currently works a 40 hour work week in the [**Hospital1 18**]
lab cleaning glassware, etc.
Tobacco: None
ETOH: None
Illicits: None


Family History:
NC

Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99.6 BP:178/69 P:95 R:14 O2:100% on RA
General: responsive but sleepy, oriented to day and ""shakiro""
only
HEENT: Sclera anicteric, pupils enlarged bilaterally s/p
cataract surgery, oropharynx clear, MM dry, no precervical LN
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, harsh gr 3 SEM loudest over LUSB, radiates through
precordium and to left carotid, S2 preserved, no rubs or gallops"
15,"8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Through [**2200-1-27**].
11. Humalog 100 unit/mL Solution Sig: ASDIR inj Subcutaneous
QACHS: Goal blood sugar
150-200 mg/dL;
For BREAKFAST:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 2 units
151-200: 4 units
201-250: 6 units
251-300: 8 units
301-350: 10 units
351-400: 12 units
>400 Notify MD"
16,"Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no HSM
Ext: Warm, well perfused, 2+ distal pulses, no edema
Neuro: CN 2-12 grossly intact, strength 5/5 in all four
extremities, finger to nose very slow, not following directions
easily and mildly disoriented, gait not assessed.


Pertinent Results:
Admission Labs:
[**2200-1-14**] 05:00PM BLOOD WBC-7.0 RBC-4.57 Hgb-12.8 Hct-37.8 MCV-83
MCH-28.0 MCHC-34.0 RDW-14.2 Plt Ct-249
[**2200-1-15**] 03:06AM BLOOD PT-14.3* PTT-39."
17,"The overall appearance is generally
unchanged with no new dominant nodules or masses.
.
[**2200-1-20**] RENAL U/S
RENAL ULTRASOUND: Both kidneys are slightly increased in
echogenicity
diffusely. The right kidney measures 9.2 cm and the left kidney
measures 10.5 cm. There is no hydronephrosis, stones or masses
of either kidney. Simple cysts are again noted of both kidneys.
The largest is located on the left, measuring up to 1.4 cm. The
urinary bladder is collapsed around a Foley catheter and
balloon.
IMPRESSION: Slightly increase in diffuse echogenicity of both
kidneys,
otherwise no change since renal ultrasound of [**2200-1-15**]."
18,"For LUNCH AND DINNER:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 1 units
151-200: 2 units
201-250: 4 units
251-300: 6 units
301-350: 8 units
351-400: 10 units
>400 Notify MD

For BEDTIME:
<76 units: give 1 amp D50
76-100: give 0 units
101-150: 0 units
151-200: 0 units
201-250: 2 units
251-300: 4 units
301-350: 6 units
351-400: 8 units
>400 Notify MD.
12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO twice a
day: please give if no BM in 2 days."
19,"This can
be seen in
chronic renal disease.
.
[**2200-1-21**] BONE SCAN
Whole body images of the skeleton were obtained in anterior and
posterior
projections and demonstrate several areas of increased uptake in
the knees, and ankles, consistent with degenerative changes.
There is also intense increased uptake in the region of L5 and a
smaller region laterally in L4. These are most likely due to
degenerative changes, however plain xray or CT imaging of the
lower lumbar spine may be of assistance for further evaluation,
if clinically indicated. The remainder of the bony skeleton
appears normal.  The kidneys and urinary bladder are visualized,
the normal route of tracer excretion."
20,"1* INR(PT)-1.2*
[**2200-1-14**] 05:00PM BLOOD Glucose-102 UreaN-64* Creat-3.0* Na-138
K-4.1 Cl-96 HCO3-30 AnGap-16
[**2200-1-15**] 03:06AM BLOOD ALT-13 AST-27 CK(CPK)-65 AlkPhos-160*
TotBili-0.6
[**2200-1-15**] 03:06AM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-12.5* Phos-3.9 Mg-2.2
[**2200-1-14**] 05:03PM BLOOD Lactate-2.2*
[**2200-1-17**] 01:00AM BLOOD WBC-4.2 RBC-3.44* Hgb-9.9* Hct-28.3*
MCV-82 MCH-28."
21,"2. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO every six (6)
hours: hold for sbp<100.
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp<100.
5. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
6. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet PO once a day as needed for constipation.
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day."
22,"Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] on [**2-12**] at 8:10
AM.

Please attend your follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of [**Hospital 18**] [**Hospital 6091**] Clinic on [**2200-2-19**] at
4:00 PM. The phone number is [**Telephone/Fax (1) 1803**] if you would like to
reschedule.

Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, confusion, chest pain, cough, shortness of
breath, abdominal pain, vomiting, diarrhea, or bloody or dark
stools.

Followup Instructions:
Please have repeat blood work done on Monday, [**1-27**].

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. Date/Time:[**2200-2-12**] 8:10

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2200-2-19**] 4:00



Completed by:[**2200-1-24**]"
23,"9 MCHC-35.1* RDW-14.1 Plt Ct-190
[**2200-1-17**] 01:00AM BLOOD Glucose-129* UreaN-47* Creat-2.7* Na-135
K-3.4 Cl-103 HCO3-25 AnGap-10
[**2200-1-15**] 03:06AM BLOOD ALT-13 AST-27 CK(CPK)-65 AlkPhos-160*
TotBili-0.6
[**2200-1-14**] 05:00PM BLOOD CK-MB-4 cTropnT-0.13*
[**2200-1-15**] 03:06AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2200-1-15**] 03:06AM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-12.5* Phos-3.9 Mg-2.2
[**2200-1-15**] 04:00PM BLOOD Calcium-12."
24,"Admission Date:  [**2158-8-4**]              Discharge Date:   [**2158-8-11**]

Date of Birth:  [**2100-8-8**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Penicillins / Iodine / clindamycin

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
S/P STEMI with cardiogenic shock

Major Surgical or Invasive Procedure:
Cardiac catheterization with percutaneous coronary
revascularization of left circumflex artery with drug eluding
stent

PICC placement


History of Present Illness:
Mr. [**Known lastname 13512**] is a 57 year-old man with ESRD on HD who presented
to [**Hospital3 **] on [**2158-8-1**] with an inferior STEMI now s/p
RCA PCI being transfered for further care.  Patient was
scheduled to have an outpatient stress test the day prior to
admission, but was unbale to participate in the study and
returned to his nursing home."
25,"No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.


R foot X ray: [**2158-8-10**]
Large ulcer extending to the calcaneal tuberosity
posteroinferiorly without gross cortical destruction. If the
ulcer probes the bone this would be highly suspicious for
osteomyelitis.


Brief Hospital Course:
Primary Reason for Hospitalization:
57M w/ HTN, DM, HLD, PVD and ESRD on HD presented to OSH with
inferior STEMI s/p PCI to RCA now transfered for further care."
26,"A PICC line was placed for IV administration
following discharge.  Patient was afebrile and hemodynamically
stable at the time of discharge.  He had two days of
surveillance cultures with no growth to date at the time of
discharge.

#Atrial fibrillation: Patient had an episode of atrial
fibrillation during his catheterization.  He was given
amiodarone, and spontaneously converted to sinus rhythm.  He
again had an episode of atrial fibrillation on HD5 and was
started on an amiodarone drip.  He spontaneously converted into
sinus rhythm again, later the same day.  He was started on oral
amiodarone with a goal loading dose of 8g."
27,"# HLD: Patient is s/p STEMI. He was changed to 40mg po
atorvastatin daily as he is also on amiodarone, and therefore
was felt to not necessitate 80mg daily.

# Right heel ulcer: Patient had a 2x4 cm ulcer on right heel
consistent with arterial insufficiency. Per report, this has
been followed by vascular surgery as an outpatient.  Patient was
evaluated by both vascular surgery and podiatry.  Both teams
agreed that the ulcer was not actively infected, and therefore
there was no indication for antibiotics.  The ulcer was cleaned
daily with application of Santil ointment.  An xray of the heel
was performed showing an ulcer but no cortical destruction."
28,"# Compliance: Patient refused many medications throughout
admission, which made regulation of blood sugar and electrolytes
difficult.  He was made aware of the risks involved in refusing
each medication.

Chronic Issues:
# DM: Patient is on oral hypoglycemics and insulin at home.
Patient's blood sugars were controlled throughout admission on a
diabetic diet and insulin sliding scale.

Transitional Issues:
- Patient maintained full code status throughout hospitalization
- Patient will need ABIs performed as outpatient.  Dressing
changes daily to heel.  Will also need to follow-up with his
vascular surgeon.
- Follow-up with ENT if hearing issues persist
-Follow- up with cardiology in approximately 2 weeks"
29,"You were admitted to our hospital because
following heart your catheterization because you required IV
medications to maintain your blood pressure.  During this
hospitalization, a previously noted blockage in your coronary
arteries was stented open.  After this, the IV medications were
slowly weaned and your blood pressure was stable off of these
medications at the time of discharge.

You were dialyzed on your normal schedule throughout admission.

In addition, you had an infection in your blood stream. One of
your blood cultures grew a bacteria called Staph Aureus. We
treated this with an IV antibiotic (vancomycin) as you are
allergic to penicillin."
30,"You will need to continue this
medication through [**2158-8-15**].

Medication changes:
You were continued on most of your home medications. But you
should STOP the following home medications:
1. Norvasc
The following home medications had their doses changed:
1. Diovan dose decreased from 160mg [**Hospital1 **] to 40 mg [**Hospital1 **]
You were started on the following NEW medications.  These
medications are very important.  Please be sure to take them
every day as prescribed.
   1.  Plavix 75 mg by mouth once each day
   2.  Aspirin 325 mg by mouth once each day
   3.  Atorvastatin 40mg by mouth once each day
   4.  Digoxin 0.125mg by mouth once a week, next dose [**2158-8-16**]
   5.  Amiodarone 300mg by mouth twice each day for 11 days. On
[**2158-8-23**] you will change this does to 200mg by mouth once each
day and continue this indefinitely.
   6.  Vancomycin IV with dialysis each time dialyzed, ending
[**2158-8-15**]. After you finish this medication your PICC line can be
safely removed.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs."
31,"Discharge exam:

Pertinent Results:
Admisson Labs:
[**2158-8-4**] 09:16PM   WBC-8.3 RBC-3.35* HGB-10.7* HCT-33.4*
MCV-100* MCH-32.0 MCHC-32.2 RDW-14.0
[**2158-8-4**] 09:16PM   PLT COUNT-189
[**2158-8-4**] 09:16PM   GLUCOSE-404* UREA N-30* CREAT-3.5* SODIUM-136
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-24 ANION GAP-23*
[**2158-8-4**] 09:16PM   CALCIUM-7.7* PHOSPHATE-4.8* MAGNESIUM-2.1
[**2158-8-4**] 09:16PM   PT-15.0* PTT-30.6 INR(PT)-1.3*

Cardiac Enzymes:
[**2158-8-4**] 09:16PM   CK(CPK)-146
[**2158-8-4**] 09:16PM   CK-MB-9 cTropnT-13."
32,"Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 9 cm.
CARDIAC:  Regular rhythm, soft S1 and S2. No m/r/g appreciated
LUNGS: Pronounced leftward chest deformity of unknown
chronicity. symmetric air movement bilaterally. End expiratory
crackles on exam, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: L BKA, No femoral bruits. right heel ulcer 2x4cm
with scant exudate and exposed bone and fat
PULSES:
Right: Carotid 2+ Femoral 2+ doplerable DP pulse
Left: Carotid 2+ Femoral 2+"
33,"No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. Overall left ventricular systolic function is
severely depressed (LVEF= 15-20 %) with global hypokinesis and
distal LV/apical akinesis to dyskinesis. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is dilated with severe
global free wall hypokinesis. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present."
34,"In particular, he denies chest and jaw pain.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
PVD
2."
35,"Medications on Admission:
HOME MEDICATIONS:
- Norvasc 10mg on non-HD days
- Sensipar 120mg daily
- Trazodone 50mg QHS
- Zocor 20mg QPM
- Diovan 160mg [**Hospital1 **]
- DuoNeb Q4H PRN
- Actos 30mg daily
- Glipizide 5mg daily
- PhosLo 3 tabs QAC
- Reglan PRN
- Atarax PRN
.
MEDICATIONS on TRANSFER:
- Acetaminophen 650 Q6H PRN
- Albuterol HFA 4 puff Q2H PRN
- Aspirin 325 daily
- Calcium Acetate 2001mg TIDQAC
- Cinacalcet 120mg QHS
- Plavix 75mg daily
- Colace 100mg [**Hospital1 **]
- Dopamine gtt
- Epoetin 8000 unit IV QHD
- Glipizide 5mg QAM
- Heparin 5000 units SQ
- Hydroxyzine 50mg Q6H PRN
- Lidoderm Patch QD
- Metoclopramide 10mg TIDQAC
- Metoprolol 6.25 Q8H
- Morphine 2mg Q5MIN
- NTG 0."
36,"Later the same evening he
developed acute SOB and was take to [**Hospital3 **] where he
was found to be having an STEMI. Cardiac catheterization
revealed severe three vessel disease with 100% occluded LAD, 90%
LCx lesion and severe RCA disease requiring BMS x3. He required
intubation during cardiac catheterization for respiratory
failure and subsequently required pressor support with
peripheral dopamine for cardiogenic shock. He is now extubated
but continues to require dopamine to maintain a SBP in the
80s-90s.
.
 On arrival his vital signs were HR 114 with BP 94/71. He is
breathing comfortably and has no complaints other than hearing
loss."
37,"4mg SL
- Zofran 4mg IV Q8H PRN
- Pantoprazole 40mg QD
- Simvastatin 10mg QHS
- Trazodone 50mg QHS
- Valsartan 160mg [**Hospital1 **]
- Insulin Sliding Scale:
201-250:3 units
251-300:5 units
301-350:7 units
351-400:9 units
>400: 11 units

Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1)  Inhalation q4h PRN SOB, wheezing.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4."
38,"digoxin 125 mcg Tablet Sig: One (1) Tablet PO 1X/WEEK ([**Doctor First Name **]):
last dose given [**2158-8-6**], next dose [**2158-8-13**].
Disp:*30 Tablet(s)* Refills:*2*
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
7. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
8. amiodarone 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) for 11 days: Then change to 200 daily."
39,"7*
[**2158-8-5**] 04:50AM BLOOD CK-MB-8 cTropnT-13.99*

Other pertinent labs:
[**2158-8-6**] 12:14PM BLOOD Lactate-2.4*

Studies
Micro:
[**2158-8-5**] 4:50 am BLOOD CULTURE      Source: Line-central lumen
cath.

   Blood Culture, Routine (Preliminary):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.

         PRELIMINARY SENSITIVITY.
         These preliminary susceptibility results are offered to
help guide
         treatment; interpret with caution as final
susceptibilities may
         change. Check for final susceptibility results in 24
hours.

                              SENSITIVITIES: MIC expressed in
MCG/ML"
40,"DIAGNOSIS:  Subarachnoid hemorrhage.

 INDICATION:  Assess for coiling.

 PROCEDURE:  Right common carotid artery arteriogram, left common carotid
 artery arteriogram, left vertebral artery arteriogram, left internal carotid
 artery arteriogram, right common femoral artery arteriogram and Angio-Seal
 closure of right common femoral artery puncture site.

 INTERVENTIONAL PROCEDURE PERFORMED:  Coil embolization of left distal A2
 anterior cerebral artery aneurysm.

 ATTENDING:[**Doctor Last Name 5877**]
 ASSISTANT:  [**First Name5 (NamePattern1) 823**] [**Last Name (NamePattern1) 27777**].

 DETAILS OF PROCEDURE:  The patient was brought to the angiography suite.
 Following this, both groins were prepped and draped in a sterile fashion.
 Access was gained to the right common femoral artery using a Seldinger
 technique and a 5 French vascular sheath was placed in the right common
 femoral artery."
41,"[**2161-8-20**] 12:59 PM
 CAROT/CEREB [**Hospital1 **]                                                  Clip # [**Clip Number (Radiology) 39238**]
 Reason: 59 year old woman with SAH, please evaluate for aneurysm
 Admitting Diagnosis: SUBARACHNOID HEMORRHAGE
  Contrast: OPTIRAY Amt: 214
 ********************************* CPT Codes ********************************
 * [**Numeric Identifier 284**] EMBO TRANSCRANIAL               [**Numeric Identifier 285**] SEL CATH 3RD ORDER [**Last Name (un) 286**]          *
 * -51 MULTI-PROCEDURE SAME DAY          [**Numeric Identifier 285**] SEL CATH 3RD ORDER [**Last Name (un) 286**]          *
 * -59 DISTINCT PROCEDURAL SERVICE       [**Numeric Identifier 285**] SEL CATH 3RD ORDER [**Last Name (un) 286**]          *
 * -59 DISTINCT PROCEDURAL SERVICE       [**Numeric Identifier 288**] CAROTID/CEREBRAL BILAT           *
 * -59 DISTINCT PROCEDURAL SERVICE       [**Numeric Identifier 821**] CAROTID/CERVICAL BILAT           *
 * -59 DISTINCT PROCEDURAL SERVICE       [**Numeric Identifier 289**] VERT/CAROTID A-GRAM              *
 * -59 DISTINCT PROCEDURAL SERVICE                                              *
 ****************************************************************************
 ______________________________________________________________________________
 [**Hospital 2**] MEDICAL CONDITION:
  59 year old woman with SAH, please evaluate for aneurysm
 REASON FOR THIS EXAMINATION:
  59 year old woman with SAH, please evaluate for aneurysm
 ______________________________________________________________________________
                                 FINAL REPORT
 DATE OF SERVICE:  [**2161-8-20**]."
42,"Both anterior and middle
 cerebral arteries are seen well.  There is a 2.2 mm aneurysm at the distal
 left A2 just before the origin of the pericallosal and callosal marginal
 artery.  The aneurysm points to the right and superiorly.

 Right common carotid artery arteriogram shows filling of the right external
 carotid artery and its branches.  The right internal carotid artery fills well
 along the cervical, petrous, cavernous and supraclinoid portion.  Both
 anterior and middle cerebral arteries are seen well.  There is a significant
 posterior communicating artery with supply to the posterior cerebral arteries.
 No aneurysms are seen on this injection."
43,"The patient
                                                             (Over)

 [**2161-8-20**] 12:59 PM
 CAROT/CEREB [**Hospital1 **]                                                  Clip # [**Clip Number (Radiology) 39238**]
 Reason: 59 year old woman with SAH, please evaluate for aneurysm
 Admitting Diagnosis: SUBARACHNOID HEMORRHAGE
  Contrast: OPTIRAY Amt: 214
 ______________________________________________________________________________
                                 FINAL REPORT
 (Cont)
 tolerated the procedure well.  A right common femoral artery arteriogram was
 done and a 6 French Angio-Seal was used for closure of the right common
 femoral artery puncture site.

 FINDINGS:  Left common carotid artery arteriogram shows that the external
 carotid artery and its branches fill well.  The left carotid bifurcation is
 clean.  The left internal carotid artery fills well along the cervical,
 petrous, cavernous and supraclinoid portion."
44,"Admission Date:  [**2161-8-20**]              Discharge Date:   [**2161-9-1**]

Date of Birth:  [**2101-11-9**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Dilantin / Ancef

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Subarachnoid Hemorrhage

Major Surgical or Invasive Procedure:
Coiling of left ACA aneurysm
Right frontal EVD

History of Present Illness:
59 y/o F with history of HTN presents s/p syncopal episode at
work. Per co-workers, patient collapsed but was caught and
placed
on the floor, no trauma to head was witnessed. She was brought
to
OSH where head CT revealed diffuse SAH. Patient was alert and
oriented per OSH notes, but had multiple episodes of n/v."
45,"She
was
intubated and sedated with fentanyl and versed and transferred
to
[**Hospital1 18**] for further neurosurgical intervention. Patient was placed
on propofol once at [**Hospital1 18**]. Per family at OSH, they state that
patient stopped taking her HTN medication about a couple months
ago. Was seen to have HTN when arrived at [**Hospital1 18**] and placed on
nicardipine gtt.


Past Medical History:
HTN

Social History:
Married
School superintedant

Family History:
Unknown

Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 3         [**Doctor Last Name **]: 4    GCS  E: 3 V: 1T Motor:6
Gen: intubated and on propofol
HEENT: atraumatic, normocephalic
Pupils: 2 minimally reactive bilaterally  EOMs: tracking"
46,"On [**8-31**],
patient was transferred to the floor. Her blood pressure was
liberalized to 90-160. She remained stable. On [**9-1**]  she
ambulated with PT and was cleared to go home.

On [**9-1**] she was discharged home.


Medications on Admission:
Unknown

Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E."
47,"****

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.

Follow-Up Appointment Instructions

??????	Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
_________, to be seen in _______weeks.
??????	You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a MRI/MRA w/ and w/o contrast ([**Doctor Last Name **] protocol)

* Staple removal 10 days from EVD removal on [**8-29**] - please call
our office to make this appointment. *****



Completed by:[**2161-9-1**]"
48,"Small saccular aneurysm arising from the distal portion of
the A2 segment of the anterior cerebral artery. Recommend
interventional neuroradiology consult and conventional angiogram
for appropriate management and detection of any other additional
aneurysms.
3. Hemorrhage extending into the thecal sac; limited assessment
of position of cerebellar tonsils.
4. Thinning/dehiscence of the bone in the postero-lateral part
of the petrous portions/carotid canal adjacent to the right
internal carotid artery without obvious extension of the artery
into middle ear.

[**2161-8-20**] CT Head:
IMPRESSION:
1. Diffuse subarachnoid hemorrhage involving the cerebral sulci,
the sylvian fissures and interhemispheric fissure, unchanged in
distribution from prior study."
49,"No vascular
occlusion is seen.


Brief Hospital Course:
Ms. [**Known lastname 8529**] was admitted to the Neurosurgery service and taken to
the angio suite emergently for an angiogram and coiling.

An External ventricular drain was placed in the INR suite
showing ICP in the 20s. A Left ACA artery aneurysm was
successfully coiled. She was transported to the ICU intubated.

Patient was extubated on post coiling day #1 and maintained a
stable and non focal neurological exam. She was febrile to 102
on [**8-22**] and a work up was initiated. She had a CTA on [**8-23**] that
showed no evidence of vasospasm."
50,"On [**8-28**] LENIs were performed which revealed no evidence of a
DVT. A routine CT performed revealed stable ventricular size,
but we opted to keep the ventricular drain in place given
intermitant elevations in her ICP. Over the next 24 hours the
patient remained neurologically stable without sustained
elevation in ICPS and so her EVD was removed on [**8-29**].  CTA was
performed after Drain removal which demonstrated improvement in
vasospasm, no hemorrhage with stable ventricular size. On [**8-30**],
patient remained stable after EVD removal and she was closely
monitored over the day for any changes in neuro exam."
51,"C.) PO DAILY (Daily) as needed for
constipation.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-18**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
6. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever,pain.
8. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours): Full 21 day course- rx called to CVS ."
52,"Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date, nods
appropriately off propofol
EO to voice
Follows simple commands
MAE

Exam on Discharge:
AOx3, [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**] w/full motor strength

Pertinent Results:
[**2161-8-20**] CTA Head:
1. Diffuse subarachnoid hemorrhage involving the cerebral sulci,
the Sylvian fissures and the interhemispheric fissure.
Effacement of the cerebral sulci from hemorrhage and some degree
of cerebral edema. Increased density in the interhemispheric
fissure as well as the parafalcine sulci due to denser
hemorrhage in that area.
2."
53,"On [**8-24**] she was febrile and CSF was sent. The gram stain was
negative and later final cultures showed no growth. Her exam
remained stable and her EVD was raised to 15 without issue. On
[**8-25**] her exam and ICPs remained stable and her EVD was raised to
20. TCDs were obtained which showed no evidence of vasospasm.
On [**8-26**], her EVD was clamped during the day.  Pt had mild
elevations while awake to around 23-25 mmHg. As a result it was
reopened. CTA on [**8-27**] revealed spasm in the A2, we elevated her
blood pressure to 160-180 and started IVF."
54,"This may indicate minimal but nonocclusive vasospasm,
but may be related to procedure.

Lower Extremity Doppler US [**2161-8-28**]:
***

Chest Xray [**8-29**]: A right subclavian central line is present, tip
at SVC/RA junction. No pneumothorax is detected.
The heart is not enlarged. The aorta is minimally unfolded. No
CHF, focal
infiltrate, or effusion is identified.

CTA Head [**2161-8-29**]: IMPRESSION:
1. Head CT shows removal of the right frontal ventricular drain
without
evidence of hydrocephalus. Blood is seen in the ventricles. No
new
hemorrhage.
2. CT angiography of the head demonstrates improvement in the
caliber of the anterior cerebral arteries without evidence of
vasospasm."
55,"Bilateral aspiration/pneumonia.

2. Slightly plump left adrenal gland with adjacent fat
stranding, concerning for left adrenal hematoma.

3. Area of wedge-shaped peripheral hypoenhancement in the upper
pole of the left kidney concerning for renal infarction. The
soft tissue stranding seen in the area of the left adrenal
gland, alternatively, could be surrounding the left renal
artery, although there is no evidence of frank left renal
arterial injury.



Brief Hospital Course:
He was admitted to the trauma team. Orthopedics was consulted
for the femur fracture and he was taken to the operating room on
[**4-15**] and [**4-18**] for repair of these injuries."
56,"3* RBC-3.71*# HGB-11.3*# HCT-32.9*#
MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6
[**2181-5-4**] 03:09PM   PLT COUNT-132*
[**2181-5-4**] 06:53AM   PT-12.0 PTT-22.4 INR(PT)-1.0
[**2181-5-4**] 06:53AM   ASA-NEG ETHANOL-104* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-5-4**] 12:53PM   GLUCOSE-147* LACTATE-4.7* NA+-141 K+-5.2
CL--111

Imaging upon admission:
CT head
IMPRESSION: No acute intracranial process.

CT c-spine
IMPRESSION: No fractures are identified. Alignment maintained.

Chest CT/Abd/Pelvis
IMPRESSION:
1."
57,"4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] hills"
58,"He is receiving
Heparin subcutaneously for DVT prophylaxis. He is on a regular
diet and taking oral narcotics for pain. Postoperatively he has
been slow to progress; he was evaluated by Physical therapy and
is being recommended for rehab.

Medications on Admission:
Synthroid

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheezing."
59,"[**2181-5-4**] 8:52 AM
 HIP UNILAT MIN 2 VIEWS LEFT                                     Clip # [**Clip Number (Radiology) 82300**]
 Reason: BETTER VIEWS OF HIP JOINT PER ORTHOPEDIC SURGEON
 ______________________________________________________________________________
 [**Hospital 2**] MEDICAL CONDITION:
  39 year old man with MVC multipartite L femur frx
 REASON FOR THIS EXAMINATION:
  please get full length femur film
 ______________________________________________________________________________
                                 FINAL REPORT
 INDICATION:  39-year-old man with motor vehicle collision, multipartite left
 femur fracture.  Please get full length femur.

 TECHNIQUE:  A total of three images of the left hip and proximal left femur
 are obtained. Evaluation is slightly limited secondary to external foreign
 stabilizing cast and rods.  There is a proximal left femur shaft fracture with
 the distal fracture fragment foreshortened by 1.5 cm and medially displaced by
 about one-shaft width.  There is no evidence of femur neck fractures or
 dislocation.

 IMPRESSION: Foreshortened and medially displaced left proximal diaphyseal
 femur fracture.  No left hip joint dislocation."
60,"SICU
   HPI:
   60 M with multiple medical issues s/p lap band on [**2133-2-2**] now here for
   large ventral hernia repair. Hernia is secondary to colostomy and
   [**Doctor Last Name **] in [**2128**] which was reversed in [**2129**] for diverticular abscess.
   s/p ex-lap, LOA, repair of the lateral/colostomy hernia with mesh
   Chief complaint:
   Large Incisional hernia repair
   PMHx:
   right bundle branch block
   ---Stress test in [**2124**] normal
   osteoporosis
   hypothyroidism s/p thyroid resection for thyroid nodule of
   undetermined significance  [**2125**]
   sigmoid diverticulitis s/p Hartmann's with small bowel resection
   ([**2129-9-2**]) and takedown ([**2129-12-16**])
   ventral hernia repaired with component separation ([**2131-5-2**])
   Current medications:
   1."
61,"Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H
   2.Levothyroxine Sodium 150 mcg
   3. Multivitamin     Tablet Sig: One (1) Tablet PO once a day
   24 Hour Events:
   [**1-27**]: Admited for observation
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Other medications:
   Flowsheet Data as of  [**2134-1-28**] 04:34 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**35**] a.m.
   Tmax: 36.6
C (97.9
   T current: 36.6
C (97.9
   HR: 90 (82 - 94) bpm
   BP: 108/70(79) {93/49(58) - 141/89(101)} mmHg
   RR: 12 (0 - 21) insp/min
   SPO2: 97%
   Heart rhythm: SR (Sinus Rhythm)
             Total In:
                                                                  5,808 mL
                                                                    652 mL
   PO:
             Tube feeding:
   IV Fluid:
                                                                  5,808 mL
                                                                    652 mL
   Blood products:
   Total out:
                                                                  1,200 mL
                                                                    375 mL
   Urine:
                                                                    185 mL
                                                                    215 mL
   NG:
   Stool:
   Drains:
                                                                    115 mL
                                                                    160 mL
   Balance:
                                                                  4,608 mL
                                                                    277 mL
   Respiratory support
   O2 Delivery Device: Venti mask
   SPO2: 97%
   ABG: ///27/
   Physical Examination
   General Appearance: No acute distress
   HEENT: PERRL
   Cardiovascular: (Rhythm: Regular)
   Respiratory / Chest: (Breath Sounds: CTA bilateral : )
   Abdominal: Soft, Non-distended, Tender: appropriately
   Left Extremities: (Edema: Absent), (Temperature: Warm)
   Right Extremities: (Edema: Absent), (Temperature: Warm)
   Skin: Abdominal wound x 3 JP
   Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
   Moves all extremities
   Labs / Radiology
   277 K/uL
   10."
62,"AUOP
   Hematology: --Hct stable
   Endocrine: RISS, --s/p thyroid resection for thyroid nodule on [**2125**] on
   Levothyroxine Sodium 150 mc daily
   Infectious Disease: --Afebrile, wbc 6.2, no issue for now
   Lines / Tubes / Drains: JP X 3, PIV, Foley
   Wounds: Clean.   Serosang from drain.
   Imaging:
   Fluids: LR 100cc/h
   Consults: General surgery, Plastics
   Billing Diagnosis: (Respiratory distress: Failure)
   ICU Care
   Nutrition:
   Glycemic Control:  Regular insulin sliding scale
   Lines:
   18 Gauge - [**2134-1-27**] 07:59 PM
   Prophylaxis:
   DVT: Boots, SQ UF Heparin
   Stress ulcer: PPI
   VAP bundle:
   Comments:
   Communication:  Comments:
   Code status:
   Disposition: Transfer to floor
   Total time spent: 20 minutes"
63,"6 g/dL
   144 mg/dL
   0.9 mg/dL
   27 mEq/L
   4.4 mEq/L
   13 mg/dL
   107 mEq/L
   139 mEq/L
   32.6 %
   6.3 K/uL
        [image002.jpg]
                             [**2134-1-27**]  08:13 PM
                             [**2134-1-27**]  09:25 PM
                             [**2134-1-28**]  03:07 AM
   WBC
   6.2
   6.3
   Hct
   33.6
   32.6
   Plt
   302
   277
   Creatinine
   0.8
   0.9
   Glucose
   183
   144
   Other labs: Ca:8.4 mg/dL, Mg:1.5 mg/dL, PO4:4.8 mg/dL
   Assessment and Plan
   Assessment and Plan: 60 M s/p ex-lap, LOA, repair of the
   lateral/colostomy hernia with mesh
   Neurologic:
   --Neuro checks Q: 4 hr, --A & O X3
   --Pain well controlled on D PCA
   Cardiovascular:
    --Hs right bundle branch block
   --HD stable on verapamil 80 po Q8H
   Pulmonary: Sating well on RA
   Gastrointestinal / Abdomen: --S/P  ex-lap, LOA, repair of the
   lateral/colostomy hernia with mesh
   Nutrition: NPO except meds
   Renal: -- Creatinine stable."
64,"SICU
   HPI:
   60 M with multiple medical issues s/p lap band on [**2133-2-2**] now here for
   large ventral hernia repair. Hernia is secondary to colostomy and
   [**Doctor Last Name **] in [**2128**] which was reversed in [**2129**] for diverticular abscess.
   s/p ex-lap, LOA, repair of the lateral/colostomy hernia with mesh
   Chief complaint:
   Large Incisional hernia repair
   PMHx:
   right bundle branch block
   ---Stress test in [**2124**] normal
   osteoporosis
   hypothyroidism s/p thyroid resection for thyroid nodule of
   undetermined significance  [**2125**]
   sigmoid diverticulitis s/p Hartmann's with small bowel resection
   ([**2129-9-2**]) and takedown ([**2129-12-16**])
   ventral hernia repaired with component separation ([**2131-5-2**])
   Current medications:
   1."
65,"Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H
   2.Levothyroxine Sodium 150 mcg
   3. Multivitamin     Tablet Sig: One (1) Tablet PO once a day
   24 Hour Events:
   [**1-27**]: Admited for observation
   Allergies:
   No Known Drug Allergies
   Last dose of Antibiotics:
   Infusions:
   Other ICU medications:
   Other medications:
   Flowsheet Data as of  [**2134-1-28**] 04:34 AM
   Vital signs
   Hemodynamic monitoring
   Fluid balance
                                                                  24 hours
                                                             Since [**35**] a.m.
   Tmax: 36.6
C (97.9
   T current: 36.6
C (97.9
   HR: 90 (82 - 94) bpm
   BP: 108/70(79) {93/49(58) - 141/89(101)} mmHg
   RR: 12 (0 - 21) insp/min
   SPO2: 97%
   Heart rhythm: SR (Sinus Rhythm)
             Total In:
                                                                  5,808 mL
                                                                    652 mL
   PO:
             Tube feeding:
   IV Fluid:
                                                                  5,808 mL
                                                                    652 mL
   Blood products:
   Total out:
                                                                  1,200 mL
                                                                    375 mL
   Urine:
                                                                    185 mL
                                                                    215 mL
   NG:
   Stool:
   Drains:
                                                                    115 mL
                                                                    160 mL
   Balance:
                                                                  4,608 mL
                                                                    277 mL
   Respiratory support
   O2 Delivery Device: Venti mask
   SPO2: 97%
   ABG: ///27/
   Physical Examination
   General Appearance: No acute distress
   HEENT: PERRL
   Cardiovascular: (Rhythm: Regular)
   Respiratory / Chest: (Breath Sounds: CTA bilateral : )
   Abdominal: Soft, Non-distended, Tender: appropriately
   Left Extremities: (Edema: Absent), (Temperature: Warm)
   Right Extremities: (Edema: Absent), (Temperature: Warm)
   Skin: Abdominal wound x 3 JP
   Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,
   Moves all extremities
   Labs / Radiology
   277 K/uL
   10."
66,"6 g/dL
   144 mg/dL
   0.9 mg/dL
   27 mEq/L
   4.4 mEq/L
   13 mg/dL
   107 mEq/L
   139 mEq/L
   32.6 %
   6.3 K/uL
        [image002.jpg]
                             [**2134-1-27**]  08:13 PM
                             [**2134-1-27**]  09:25 PM
                             [**2134-1-28**]  03:07 AM
   WBC
   6.2
   6.3
   Hct
   33.6
   32.6
   Plt
   302
   277
   Creatinine
   0.8
   0.9
   Glucose
   183
   144
   Other labs: Ca:8.4 mg/dL, Mg:1.5 mg/dL, PO4:4.8 mg/dL
   Assessment and Plan
   Assessment and Plan: 60 M s/p ex-lap, LOA, repair of the
   lateral/colostomy hernia with mesh
   Neurologic:
   --Neuro checks Q: 4 hr, --A & O X3
   --Pain well controlled on D PCA
   Cardiovascular:
    --Hs right bundle branch block
   --HD stable on verapamil 80 po Q8H
   Pulmonary: Sating well on RA
   Gastrointestinal / Abdomen: --S/P  ex-lap, LOA, repair of the
   lateral/colostomy hernia with mesh
   Nutrition: NPO except meds
   Renal: -- Creatinine stable. AUOP
   Hematology: --Hct stable
   Endocrine: RISS, --s/p thyroid resection for thyroid nodule on [**2125**] on
   Levothyroxine Sodium 150 mc daily
   Infectious Disease: --Afebrile, wbc 6.2, no issue for now
   Lines / Tubes / Drains: JP X 3, PIV, Foley
   Wounds:
   Imaging:
   Fluids: LR 100cc/h
   Consults: General surgery, Plastics
   Billing Diagnosis: (Respiratory distress: Failure)
   ICU Care
   Nutrition:
   Glycemic Control:  Regular insulin sliding scale
   Lines:
   18 Gauge - [**2134-1-27**] 07:59 PM
   Prophylaxis:
   DVT: Boots, SQ UF Heparin
   Stress ulcer: PPI
   VAP bundle:
   Comments:
   Communication:  Comments:
   Code status:
   Disposition: Transfer to floor
   Total time spent: 20 minutes"
67,"He was able to lose
weight preoperatively with the aid of the Lap-Band procedure
and now he required surgical repair of his hernias.

Past Medical History:
right bundle branch block
---Stress test in [**2124**] normal
osteoporosis
hypothyroidism s/p thyroid resection for thyroid nodule of
undetermined significance
sigmoid diverticulitis s/p Hartmann's with small bowel resection
([**2129-9-2**]) and takedown ([**2129-12-16**])
ventral hernia repaired with component separation ([**2131-5-2**])

Social History:
The patient quit tobacco 20 years ago, does drink one glass of
wine per night.  No drugs.  Works as mail carrier, lives with
wife."
68,"Pulm - After surgery the patient was encouraged to use his
incentive spirometer 10 times/hour; the patient was compliant
and had not postoperative complications with his pulmonary
function.  He maintained his oxygen saturations in the mid-90s
on room air at the time of discharge.

GI - The patient underwent an open hernia repair on [**1-28**] by Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **] (plastic surgery).  His post-operative
course was complicated by an ileus secondary to narcotics whichw
as relieved by a suppository.  Prior to discharge the patient
was passing gas, defecating, and tolerating a Stage V diet
without nausea or vomiting."
69,"5 Tablets PO DAILY
(Daily).


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Ventral Hernia


Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent


Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST  refrain from such activities while
taking these medications.


Please call your doctor or return to the emergency room if you
have any of the following:

 * You experience new chest pain, pressure, squeezing or
 tightness."
70,"Activity:
No heavy lifting of items [**9-17**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.

Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please call his
office at [**Telephone/Fax (1) 3201**] to make an appointment.

Please follow up with Dr. [**First Name (STitle) **], please call his office at
[**Telephone/Fax (1) 6742**] to make an appointment.

Please make an appointment with your primary care provider in
the next month to review your current health status.



Completed by:[**2134-2-8**]"
71,"Admission Date:  [**2134-1-27**]              Discharge Date:   [**2134-2-5**]

Date of Birth:  [**2073-8-18**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Admitted for repair of hernia.

Major Surgical or Invasive Procedure:
[**2134-1-27**]
1. Exploratory laparotomy with biopsy of mesenteric nodule.
2. Lysis of adhesions greater than 2 hours.
[**2134-2-2**] PICC line placement


History of Present Illness:
Mr. [**Known lastname 29215**] has the history of multiple
abdominal surgeries including hernia repairs with mesh. He
presented with very large abdominal wall hernias with
intermittent and recurrent obstruction."
72,"* New or worsening cough or wheezing.

* If you are vomiting and cannot keep in fluids or your
 medications.

* You are getting dehydrated due to continued vomiting,
 diarrhea or other reasons. Signs of dehydration include dry
 mouth, rapid heartbeat or feeling dizzy or faint when standing.

* You see blood or dark/black material when you vomit or have a
 bowel movement.


* You have shaking chills, or a fever greater than 101.5 (F)
 degrees or 38(C) degrees.

* Any serious change in your symptoms, or any new symptoms that
 concern you.

* Please resume all regular home medications and take any new
meds
 as ordered."
73,"Three JP drains were placed. Pt did well, made good
urine, vital signs were stable and so on [**1-28**] pt was transfered
to the floor. On [**1-29**] foley was removed diet was advanced.
Laboratory results and vital signs remained stable. JP drainage
was reduced.

Neuro - Patient's pain was well controlled with a dilaudid PCA
until the patient was tolerating POs at which point he was
transitioned to Percocet which offered good relief for his pain.

CV - The patient's vital signs were monitored per routine on the
floor after surgery.  He was hemodynamically stable throughout
the entirety of his hospital course."
74,"Integumentary - The patient's incision was monitored for
cellulitis on a daily basis and showed no signs of infection
during his postoperative stay.  He was kept on Ancef for
prophylaxis while his JP drains were in.  All JPs and the Ancef
were discontinued on the day of discharge.

Medications on Admission:
1. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H
2.Levothyroxine Sodium 150 mcg
3. Multivitamin Tablet Sig: One (1) Tablet PO once a day


Discharge Medications:
1. Verapamil 40 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
2. Levothyroxine 100 mcg Tablet Sig: 1."
75,"The neck veins are flat when he is about 30 degrees
from the fully supine position. The trachea is midline.

There is no pain with percussion of the vertebral bodies or the
CVAs. The thorax is resonant, and the BS are clear and symmetric
in all lung fields, including the apices, RML and the lingula.

The precordium is quiet and there is a soft and regular s1 and
s2
and no murmurs, no s3 or s4 when he is upright and supine. There
are no carotid bruits. No cardiac rubs.

The abdomen has active BS. The liver is 9 cm in span by
percussion and scratch."
76,"He has at least 2 very large ventral
hernias. No abdominal masses.

No peripheral edema, and no acute joint pathology. He is alert
and orientated.


Pertinent Results:
[**2134-1-27**] 09:25PM BLOOD WBC-6.2 RBC-3.34* Hgb-11.2* Hct-33.6*
MCV-101* MCH-33.7* MCHC-33.5 RDW-13.2 Plt Ct-302
[**2134-1-28**] 03:07AM BLOOD WBC-6.3 RBC-3.29* Hgb-10.6* Hct-32.6*
MCV-99* MCH-32.4* MCHC-32.6 RDW-13.5 Plt Ct-277
[**2134-1-27**] 08:13PM BLOOD Glucose-183* UreaN-13 Creat-0."
77,"8 Na-140
K-4.4 Cl-107 HCO3-26 AnGap-11
[**2134-1-28**] 03:07AM BLOOD Glucose-144* UreaN-13 Creat-0.9 Na-139
K-4.4 Cl-107 HCO3-27 AnGap-9
[**2134-1-27**] 08:13PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.5*
[**2134-1-28**] 03:07AM BLOOD Calcium-8.4 Phos-4.8*

Brief Hospital Course:
Pt underwent open heria repair on [**1-28**] with Dr. [**Last Name (STitle) **] and
then Dr. [**First Name (STitle) **] from Plastics did the reconstruction. Procedure
lasted over 10 hours and so pt was transfered to ICU after
surgery."
78,"Family History:
Non-contributory -- as per HPI no h/o blood clots,
coagulaopathies, or miscarriages

Physical Exam:
The BP is 116/74 and his pulse is 72 and regular. Resp is 14 and
unlabored after walking down the hallway. The temp is 98.2
orally.

There are no acute skin lesions. The hair and nails are normal
for his age. The ear canals are clear with benign TMs. The
sclera
are anicteric and w/o pallor. PERRL and A. The oral mucosa has
no
lesions; dentition is in good repair.

The neck is supple, and the thyroid is w/o enlargment or
nodularity."