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."