| 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. |
| . |
| |
| 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. |
| . |
| |
| days. |
| . |
| |
| setting of hypoglycemia and were not restarted due to renal |
| insufficiency." |
| 6,"She was started on basal and sliding scale |
| insulin, as above. |
| . |
| |
| 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: |
| |
| 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. |
| . |
| |
| 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. |
|
|
| |
| 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. |
|
|
| |
| 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: |
| |
| 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 |
| 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 |
| 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 |
| 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 |
| 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." |
|
|
