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train_2544 | completed | 65d6975c-f25e-4076-8c1f-326271d43dcf | Medical Text: Admission Date: [**2178-10-17**] Discharge Date: [**2178-10-20**]
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
resp distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo female with recent dx of metastatic adenocarcinoma of the
gallbladder with invasion of hte right colon and with liver
metastasis now s/p ccy and right colectomy presents from her
rehab facility with worsening resp status. Pt initally admitted
to [**Hospital1 18**] [**Last Name (un) 4068**] on [**2178-8-29**] with abd pain. CT scan showed mass
in BG. Pt underwent open laparotomy. Her post-op course was
complicated by GI bleed felt to be [**2-5**] erosions at anastomotic
site, CHF with labile BP after diresis, hypercarbic resp
failure, PNA with highly resistent Enterobacter, Pseudomonas and
MRSA, treated with 14 days of Vanc, Aztreonam and Flagyl. She
was discharged to rehab facility on [**10-12**] with the regimen of 4
hours on Bipap and 4 hours off due to her hypercarbic resp
failure. Over the last day, pt required continuous BIPAP and
has had worsening resp status.
.
In [**Name (NI) **], pt found to have ABG of 7.25/81/145. Pt received
Vanc/Levo/Flagyl for presumed PNA and elevated WBC. Pt is
DNR/DNI.
Past Medical History:
htn
secondary av block s/p pacemaker
avr tissue
hypothyroidism s/p thryoidectomy
polymyalgia rheumatica
osteoarthritis
GI bleed
Social History:
unable to obtain
Family History:
unable to obtain
Physical Exam:
95.3 65 120/73 22 100% on BIPAP 50%
GEN: somnelent but arousable; answers to name. Responds to yes,
no.
HEENT: MM dry
NECK: supple, elevated JVD
CV: distant heart sounds, regular, no murmurs
PULM: difficult to assess due to bipap, no rales or rhonchi at
bases
ABD: well healed scar at midline; gtube intact
EXT: anasarca, right arm more edematous than left; bilateral LE
edema to knees
NEURO: somnelent. Moving all ext.
Pertinent Results:
.
134 93 80
-------------< 154
4.7 32 1.1
14.4 > 11.7 < 290
35.8
N:88.8 L:8.0 M:2.6 E:0.1 Bas:0.4
PT: 11.7 PTT: 33.0 INR: 1.0
proBNP: [**Numeric Identifier **]
CXR: Cardiac failure. Small left pleural effusion with adjacent
retrocardiac atelectasis/consolidation.
UE US: No evidence of DVT in the right upper extremity.
Brief Hospital Course:
89 yo f with metastatic cholangiocarcinoma p/w worsening
hypercarbic resp failure.
.
# RESP FAILURE:
Pt had ongoing hypercarbic resp failure requiring intermittent
BIPAP at nursing home, then requiring full time bipap on
admission. Resp failure was [**2-5**] decompensated CHF, which was
evident on physical exam and on xray. Her BNP was over 60,000.
The goal was to diurese her with IV lasix but this was limited
by her low bp.
.
She was afebrile but she had leukocytosis with left shift, which
raises the possibility of PNA also. She was pan-cultured and
started emperically on vanc and meropenem.
.
She continued to decompensate, becoming acidemic, hypoxic and
hypercarbic. She developed acute renal failure from diuresis
and poor foward flow. The family decided, given the patients
multiple medical problems including a poor prognosis from
metastatic cholangiocarcinoma and end stage heart failure, to
make the patient comfort measure only.
.
The patient expired on [**2178-10-20**] at 4:35 AM.
.
# UTI: culture sent. Covered emperically with vanc and
meropenem.
.
# Cholangiocarcinoma: Pt has metastasis to liver and colon, s/p
ccy and right colectomy. There were no futher plans for
intervention.
.
# PMR: chronic steroids
Medications on Admission:
florinef 0.1 mg daily
lopresor 12.5 daily
lovenox 40 daily
prednisone 5 daily
lasix 40 [**Hospital1 **]
synthroid 125 daily
mag-ox
timoptic eye gtt
Discharge Medications:
Pt expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt expired.
Discharge Condition:
Pt expired.
Completed by:[**2178-12-14**]
ICD9 Codes: 5859, 5990, 4280, 5849 | [
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train_1958 | completed | 9b73efdf-5bcb-45f9-a166-e73f667e23b8 | Medical Text: Admission Date: [**2121-8-8**] Discharge Date: [**2121-8-12**]
Date of Birth: [**2036-10-16**] Sex: F
Service: MEDICINE
Allergies:
lisinopril / morphine / Oxycodone
Attending:[**Last Name (un) 2888**]
Chief Complaint:
short of breath
Major Surgical or Invasive Procedure:
aortic valvuloplasty [**8-11**]
History of Present Illness:
REASON FOR TRANSFER: need for BiPAP
HISTORY OF PRESENTING ILLNESS:
84 yo with critical aortic stenosis, diastolic heart failure (EF
65%), CAD admitted to [**Hospital1 18**] for surgical evaluation of AS
transferred to CCU due to need for BiPAP.
Patient was initially admitted to [**Hospital1 **] [**Location (un) 620**] with respiratory
distress, thought to be secondary to flash pulmonary edema. She
was initially placed on BIPAP and diuresised with IV lasix.
Course at [**Location (un) 620**] was complicated by UTI with administration of
CTX. Her creatinine was 2.2 from 2.3 with diuresis. Her heart
rate was well controlled, and was continued on her home
metoprolol. She was transferred to [**Hospital1 18**] for surgical evaluation
for her aortic stenosis and possible balloon aortic
valvuloplasty.
On arrival to BIDNC discussion involving mgmt of AS ensued and
decision was made to precede with ballon angioplasty on [**8-11**]. On
[**8-10**] patient triggered twice for tachypnea. Initially patient
responded to 20mgIV lasix (received a total of 40mg IV) however
again became tachypneic and less responsive so discussion was
made to transfer to the CCU for initiation of BiPAP. Prior to
transfer patient received additional 20mg IV lasix and ipratrium
nebulizer.
Vitals on transfer were 130/50 80-90sAF RR: 24-28 98-100
3-4LNC.
On arrival to the CCU, patient minimally interactive and patient
started on BiPAP.
REVIEW OF SYSTEMS
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/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:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
Critical aortic stenosis
Diastolic congestive heart failure (EF 65%)
Coronary artery disease s/p MI x 2
Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
Myelodysplastic syndrome
Diabetes mellitus
Chronic kidney disease, baseline creatinine 1.7
Peripheral [**Month/Year (2) 1106**] disease
Peripheral neuropathy
Gout
Anemia of chronic disease
Bilateral carotid artery stenosis
Dementia
Peptic ulcer disease
Osteoarthritis
Depression
Anxiety
MEDICATIONS: (home)
Januvia 100 mg PO daily
Gabapentin 100 mg PO daily
Mirtazapine 30 mg PO daily
Carvedilol 25 mg PO BID
Torsemide 60 mg PO daily
Docusate 100 mg PO daily
Pravastatin 80 mg PO daily
Clopidogrel 75 mg PO daily
Vitamin B12 500 mg PO daily
Omeprazole 20 mg PO daily
Allopurinol 200 mg PO daily
Warfarin 2 mg daily alternating with 3 mg PO daily
Folic acid 1 mg PO daily
Trazodone 100 mg PO daily
ALLERGIES:
Lisinopril (hyperkalemia)
Social History:
Lives at home. Uses a walker. Quit smoking several years ago. No
alcohol or drug abuse.
Family History:
Non-contributory
Physical Exam:
VS: T= 97.8 BP=127/57 HR=85 Afib RR=20 O2 sat=100% on Bipap
GENERAL: Depressed affect, Bipap on
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. systolic ejection murmur in RUSB
LUNGS: Scan crackles in RLL, rhonchi over left
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema in bilateral lower extremities,
radial pulses 1+, DP pulses 1+. Patient mildly cool to touch,
small area of warmth and erythema over dorsal aspect of L shin
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Procedures: Coronary Angiography, RLHC, Balloon aortic
valvuloplasty
Indications: Critical aortic stenosis
Staff
Diagnostic Physician [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Fellow [**Name6 (MD) **] [**Name8 (MD) **], MD
Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6185**], RN
Nurse [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6692**], RN
Technologist [**Doctor First Name **] Hokinson, RTR
Technologist [**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5239**], EMT,RCIS
Technical
Anesthesia: Local
Specimens: None
Catheter placement via 5 French pulmonary artery catheter
Coronary angiography using 5 French JL3.5 JR4, Dual lumen
pigtail
Blood Oximetry Information
Baseline
Time Site Hgb(gm/dL) Sat (%) PO2 (mmHg) Content (ml per dl)
10:09 AM PA 7.80 63 6.68
10:16 AM AO 7.80 100 10.61
Cardiac Output Results
Phase Fick C.O.(l/min) Fick C.I. (l/min /m2) TD
CO (l/min) 3.30 2.11
Hemodynamic Measurements (mmHg) Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
PCW 30 22 30 65
AO 127 46 78 62
PA 75 34 55 62
ART 100 62
RV 77 16 25 58
RA 23 28 26 58
Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
LV 154 27 32 62
AO 137 47 81 59
Valve Results
Contrast Summary
Contrast Total (ml)
Omnipaque (300 mg/ml) 35
Radiation Dosage
Effective Equivalent Dose Index (mGy) 386
Radiology Summary
Total Runs
Total Fluoro Time (minutes) 15.7
Findings
ESTIMATED blood loss: < 25 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: Moderate diffuse lumen irregularities up to 50%
LAD: Moderate diffuse lumen irregularities up to 50%
LCX: Moderate diffuse lumen irregularities up to 50%
RCA: Left dominant
Interventional details
The patient was placed under general anesthesia and the
procedure
was performed under TEE guidance. The left brachial artery was
exposed by surgical technique and coronary arteriography was
performed from the left brachial artery.
The aortic valve was then crossed with a 0.014 straight wire and
a pigtail catheter was placed in the left ventricle for
simultaneous pressure recordings.
A 0.035 Amplatz SuperStiff guidewire was placed in the left
ventricle and a single balloon inflation was performed using a
18
mm Tyshak II balloon.
Immediately after balloon deflation, the patient developed
marked
hypotension. There was no evidence of aortic regurgitation and
no evidence of pericardial fluid.
CPR was initiated but the left ventricular contractility
continued to worsen.
The patient expired at 11:11 AM.
The family was notified.
Assessment & Recommendations
1. Severe aortic stenosis
2. Non obstructive but diffuse coronary artery disease
3. Unsuccessful balloon aortic valvuloplasty resulting in death
______________________________________
Brief Hospital Course:
Ms [**Known lastname 32651**] is a 85 y/o F with PMHx of critical aortic stenosis,
CAD, DM2, transferred to the CCU for worsening respiratory
distress who underwent aortic valvuplasty with procedure
complicated by refractory hypotension and asystolic arrest.
# PUMP: Patient with known critical AS and transferred to CCU
for monitoring of heart failure symptoms prior to valvuloplasty.
She was on bipap briefly and then given lasix IV prn for
diuresis. Pt was stabilized for 48hrs prior to procedure. She
underwent elective valvuloplasty on [**8-12**]. Unfortunately
immediately after balloon deflation, the patient developed
marked hypotension. Per cath report there was no evidence of
aortic regurgitation and no evidence of pericardial fluid. CPR
was initiated but the left ventricular contractility continued
to worsen. Patient died on [**8-12**]. Family was notified.
#Anxiety: Patient had lots of anxiety leading up to procdure and
was treated with zyprexa.
#LLE Cellulitis. Treated with Vancomycin in house.
CHRONIC ISSUES
# Afib. Rate controlled in house. Coumadin was held on arrival
in plan for procedure.
# CAD, Patient with known occlusion of OM1 by CTA and
calcifications of widespread coronaries s/p MIx2. In house
contineud on home plavix 75mg, pravastatin 80 mg daily
# Diabetes mellitus type 2. Maintained on ISS + lantus in house
# Peripheral neuropathy. Continued on renally dosed Gabapentin
100 mg q 24 hrs
#PUD. Continued on Omeprazole 20 mg daily
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
2. Gabapentin 100 mg PO DAILY
3. Mirtazapine 30 mg PO HS
4. Carvedilol 25 mg PO BID
hold for sbp<95, hr<55
5. Torsemide 60 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Allopurinol 200 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Warfarin 2 mg PO DAILY16
14. traZODONE 100 mg PO HS:PRN insomnia
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Aortic Stenosis
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
ICD9 Codes: 2724, 412, 5859, 4439, 2749, 311, 4241, 5990, 2762, 5849, 4280 | [
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train_2715 | completed | ed32484f-e4be-4718-87bd-36b03be786d5 | Medical Text: Admission Date: [**2194-6-1**] Discharge Date: [**2194-6-7**]
Date of Birth: [**2128-6-13**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
Caucasian gentleman who presented to the [**Hospital1 346**] Emergency Department from an outside
hospital for three episodes of spiking fevers, significant
chills, and rigors, dyspnea, and tachypnea, and episodes of
delirium. The patient states this started Thursday at around
3:00 p.m. when he was driving home for work, but he did not
measure his temperature. After one hour of feeling very hot,
having chills, and extreme rigors the patient stated the
episode went away. Again, he had this same episode with
diaphoresis, chills, rigors, tachypnea, and a fever to 104
degrees Fahrenheit on Friday. The patient was admitted to an
outside hospital - which was [**Hospital6 6640**].
The patient had another episode on the morning of admission
to [**Hospital1 69**]. While at the
outside hospital, he was worked up for fever of unknown
origin with an unknown infectious site. The patient had two
episodes of rigors at the outside hospital with fevers to
105. Per the patient, he had a lumbar puncture under
fluoroscopy and a negative head computer tomography. He had
a negative KUB, and blood cultures that were drawn. The
patient's vital signs other than fever were stable except for
a desaturation to the low 80s during his rigorous episodes.
The rigorous episodes needed Tylenol; although, this did not
shorten the course of the episode but did bring the fever
down.
He denies any recent travel history, visits or exposures to
forests or [**Last Name (LF) 6641**], [**First Name3 (LF) 691**] ingestion of recent raw or undercooked
food. All other review of systems were essentially negative.
The patient has no trauma and no obvious signs of puncture.
No obvious infectious exposures. The patient denies any
chest pain, palpitations, nausea, vomiting, diarrhea,
constipation, or abdominal pain - but does state some
dysuria, hesitancy, and urgency, and the feeling of being
dehydrated. The patient denies a cough, headache, neck pain,
photophobia, recent trauma, blood in the urine, blood from
any other orifice, cold symptoms, myalgias, arthralgias, or
any recent symptoms of this kind.
The patient's daughter states that during these rigorous
episodes the patient gets delirious and misnames common
objects that are around the room. An example, was he called
a person an envelope. He had been anxious since Thursday,
especially during these rigorous episodes; and, per the
daughter, he was agitated and not himself.
The patient's past medical history is significant for
multiple uric acid stones, which the patient feels may be
leading to this presentation. The patient states about one
year ago he was diagnosed with urate stone at the outside
hospital, but nothing was done for it, and he does feel he
has passed the stone either.
PAST MEDICAL HISTORY: Hypertension.
Gastroesophageal reflux disease.
Coronary artery disease; status post myocardial infarction in
[**2182**].
Status post angioplasty.
Degenerative joint disease.
History of recurrent urate stones.
PAST SURGICAL HISTORY: Status post angioplasty in [**2172**].
MEDICATIONS ON ADMISSION: Aspirin, Zantac, and he denies any
herbal medications.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He denies any alcohol or intravenous drug
abuse. He states a smoking history of one and a half packs
of cigarettes times 50 years.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
his temperature was 98.4, his blood pressure was 134/80, his
pulse was 92, his respiratory rate was 24, and he was
saturating 99 percent on 3 liters. General physical
examination revealed he was anxious appearing and appropriate
for age. He was in no acute distress. He was alert and
oriented times three. Head, eyes, ears, nose, and throat
examination revealed the pupils were equal, round, and
reactive to light and accommodation. The extraocular muscles
were intact. The mucous membranes were dry. Cardiovascular
examination revealed distant heart sounds. A regular rate
and rhythm. There were no murmurs. First heart sounds and
second heart sounds. On pulmonary examination, he had
prolonged expirations and mild rales in the left middle lobe,
and left lower lobe, and the right lower lobe. The abdomen
was distended. The abdomen was soft. There were positive
bowel sounds. The abdomen was nontender. There was no
hepatosplenomegaly. He was passing flatus. Extremity
examination revealed no clubbing, cyanosis, or edema. No
visibile puncture wounds. There was no costovertebral angle
tenderness. There was no flank tenderness. Neurologic
examination revealed cranial nerves II through XII were
grossly intact. There was presence of high cortical
function. No focal deficits. No changes in sensation. Mini-
Mental Status Examination was greater than 28.
PERTINENT LABORATORY VALUES FROM THE OUTSIDE HOSPITAL: The
lumbar puncture under fluoroscopy showed no organisms. Gram
stain, there was 1 white blood cell, 7 red blood cells,
clear, with a pending culture. Blood cultures from the
outside hospital showed gram-negatives growing in anaerobic
bottles [**1-13**].
RADIOLOGY: As stated before, a head computer tomography and
KUB - per outside hospital - were also negative.
A chest x-ray showed no acute process.
PERTINENT LABORATORY VALUES IN HOUSE: Negative urinalysis in
house, showed 2 plus protein, large blood, 20 to 30
epithelials, and leukocyte esterase negative. White blood
cell count was 3.1, his hematocrit was 44, and his platelets
were 100. Polymorphonuclear neutrophils of 77 percent.
Erythrocyte sedimentation rate was 8. Sodium was 140,
potassium was 3.4, chloride was 108, bicarbonate was 26,
blood urea nitrogen was 7, creatinine was 0.5, and his blood
glucose was 128. His troponin was less than 0.02. His
albumin was 3.6. His INR was 1.5.
SUMMARY OF HOSPITAL COURSE: The patient is a 65-year-old
gentleman with a 3-day history of fever of unknown origin
with rigors, chills, tachypnea, and episodes of tachycardia
with delirium who was admitted from an outside hospital. The
patient was initially worked up because of the rales found on
his physical examination as well as some signs suggestive of
either congestive heart failure or pneumonia found on chest x-
ray. He was initially diagnosed with pneumonia and was
started on Levaquin and Flagyl for a possible aspiration
pneumonia.
The patient continued to have these rigor episodes while on
Levaquin and Flagyl, and other etiologies were also pursued.
As the only imaging not done at the outside hospital -
including his abdomen and with a history of uric acid stones
and questionable picture of urosepsis, the patient received a
computer tomography of the abdomen which showed a left portal
vein septic thrombus.
During the first day of his admission, the patient had one
episode of rigors and chills which lasted for one hour with a
temperature to 105 - per axillary [**Location (un) 1131**]- as well as
tachycardia into the 140s (which was normal sinus). The
patient had to be put on 10 liters of nonrebreather to keep
his oxygen saturations above 90 percent. The patient was
given Tylenol. The patient was normalized within one hour
with a normal temperature, a normal heart rate, and not
having any oxygen requirement at all.
After the left portal vein septic thrombus was found on the
computed tomography scan, the patient was immediately moved
to the Surgical Intensive Care Unit for further observation.
Blood cultures were again drawn, and the patient was changed
to ceftriaxone and azithromycin. While in the Intensive Care
Unit the patient was seen by Surgery who did not feel that
the patient had any acute surgical needs. Discussion, per
the surgeons with the Interventional radiologists - all
agreed that the thrombus was stable at present (as confirmed
by a follow-up magnetic resonance imaging) that no surgical
intervention was necessary for removal of this clot.
The patient was started on Zosyn and then gentamicin was
later added. He continued to spike fevers to 101 while in
the Surgical Intensive Care Unit; although, he did not have
any of his rigorous episodes. The patient continued to have
crackles at bibasilar base. Because of the correlation with
chest x-ray it was later assumed to be congestive heart
failure either from diastolic dysfunction from his
tachycardia or an underlying congestive heart failure
picture; that was also given to using gentamicin, Flagyl, and
ampicillin. It was discussed whether or not the patient
should be anticoagulated. It was later decreased that
anticoagulation would most likely be necessary at a weight-
based protocol dose for a clot and was started on the day
prior to discharge.
Throughout his hospital course, the patient - after being in
the [**Hospital Ward Name 332**] Intensive Care Unit for 24 hours being afebrile -
was sent back up to the floor. While upon the floor, the
patient was afebrile for at least 48 hours. He never
complained of abdominal pain. Of note, the patient never did
complain of abdominal pain on admission or while in the
[**Hospital Ward Name 332**] Intensive Care Unit. The patient's white blood cell
count had normalized, and the patient did not have any
rigorous episodes his initial presentation.
On the day of discharge, the patient is on Zosyn and
gentamicin - which are per Infectious Disease recommendations
is being changed to Levaquin and Flagyl for four weeks.
Because a left portal vein thrombus is not very common
occurrence, and because the literature is very sparse in
terms of the most efficacious treatment, the patient is going
to be on Levaquin and Flagyl for coverage for anaerobes and
gastrointestinal flora and will be given Lovenox and Coumadin
for anticoagulation to dissolve the clot.
The patient has follow-up appointments with the Infectious
Disease Clinic in four weeks. The patient has an appointment
for an outpatient computer tomography of his abdomen to see
if there are any interval changes in the size of the clot
and/or the location of the clot in his left portal vein for
three and a half weeks. The patient was also to meet with a
hematologist - Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] - in five weeks for
a workup of hypercoagulable state; as normally an underlying
hypercoagulable state is necessary before a left portal vein
thrombus is produced.
Computer tomography findings were also suggestive of a
resolving diverticulitis that may have led to this left
portal vein thrombus. The patient stated he had recently had
a colonoscopy which showed a diverticulosis and was unaware
of what the correct diet for a patient with diverticulosis
should be. The patient was seen by the Nutrition Service and
was started on a low-residue diet for three weeks, to be
slowly advanced as tolerated. The patient notes that he
frequent servings of nuts and popcorn before admission, but
he did not recall any acute diverticulitis type symptoms
before presentation of the rigors to the outside hospital.
Blood cultures from the outside hospital confirmed anaerobic
bottles grew out Prevotella melaninogenica and Bacteroides
fragilis, but no blood cultures or urine cultures from in
house have grown any organisms. Because of being started on
Lovenox and Coumadin, the patient was to have his INR checked
in three days at his [**Hospital 6642**] Hospital. He is having liver
function tests checked in two weeks. The workup for any
liver manifestations of his diverticulitis and left portal
vein thrombus were also worked up; although, his liver
function tests at the highest were in the 60s, and upon
discharge were in the 50s and 30s. The patient did not show
any laboratory values of an obstructive bile pathology as his
bilirubin and alkaline phosphatase were normal throughout his
admission.
Three days prior to discharge, the patient noted have some
loose stools - about two to three per day - which were green
in color; although not watery in consistency. A Clostridium
difficile toxin times two were negative before discharge, and
the patient did not have any diarrhea on the day of
discharge. The patient was given Lovenox teaching prior to
discharge and understood that he had to continue both Lovenox
and Coumadin until his INR is therapeutic. The patient also
understood to take his Levaquin and Flagyl for at least four
weeks until he sees the Infectious Disease physicians - whom
it will be up to regarding make a decision regarding
discontinuance of the antibiotics in four weeks. The patient
also understood that he was to have his INR and liver
function tests checked and have a computer tomography of the
abdomen in the future. The patient also understood to see
the hematologist regarding when to discontinue his Coumadin
and when to not be anticoagulated any longer as well as for a
workup of hypercoagulability. The patient was also given a
prescription for hypercoagulability laboratories which are to
be drawn at the [**Location (un) 448**] of the [**Hospital 469**] Clinic Laboratory
before he presents to the hematologist.
DISCHARGE DIAGNOSES: Pylephlebitis in the left portal vein.
Status post diverticulitis; continuous diverticulosis.
Coronary artery disease.
Congestive heart failure.
Degenerative joint disease.
History of recurrent urate stones.
Hypertension.
MEDICATIONS ON DISCHARGE:
1. Levaquin 500 mg once per day (times 30 days).
2. Flagyl 500 mg three times per day (times 30 days).
3. Lisinopril 5-mg tablets take one-half tablet by mouth once
per day.
4. Zantac 150-mg tablets one tablet by mouth twice per day.
DISCHARGE INSTRUCTIONS: Prescription to have blood draw for
prothrombin time and INR on [**6-10**] and [**6-13**] and to have
the results faxed or called to the patient's primary care
physician [**Name Initial (PRE) **] [**Name10 (NameIs) 6643**] is Dr. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] (fax number [**Telephone/Fax (1) 6645**]). The patient to be on both Lovenox and Coumadin. The
patient may stop Lovenox injections upon advice of his
primary care physician when his INR is normalized.
The patient was instructed to have to have blood drawn for
aspartate aminotransferase and alanine-aminotransferase in
two weeks; and then in four weeks at Adelboro Laboratory and
have the results telephoned or faxed to his primary care
physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] - (fax number [**Telephone/Fax (1) 6646**]).
The patient was instructed to follow the advice of his
primary care physician regarding medication changes if
necessary, as the patient is on Lovenox, Coumadin, and
chronic antibiotics.
The patient was instructed to have his blood drawn at the
[**Hospital 469**] Clinic - [**Location (un) 448**] laboratory - at least three
days prior to his [**7-14**] appointment with the hematologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**]. These laboratories should include
C protein, S protein, antithrombin III lupus anticoagulant,
homocystine, and factor V Leiden.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] - the hematologist - in five weeks,
on [**7-14**] at 10:00 a.m. on the ninth floor of the [**Hospital 469**]
Clinic. The patient to have his blood drawn for C protein, S
protein, lupus anticoagulant, homocystine, factor V Leiden at
least three days prior to his appointment; for which a
prescription was given.
The patient was instructed to follow up with Dr. [**First Name4 (NamePattern1) 6647**] [**Last Name (NamePattern1) **]-
[**Doctor Last Name **] in the [**Last Name (un) 2577**] Building - Infectious Disease Clinic -
(telephone number [**Telephone/Fax (1) 457**]) on [**2194-7-1**] at 1:00 p.m.
The patient was scheduled for an outpatient computed
tomography scan of the abdomen which is scheduled for [**2194-7-10**].
The patient was instructed to contact his primary care
physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 6644**] [**Last Name (NamePattern1) **] - regarding his admission to the
[**Hospital1 69**]. The patient was to
have his Discharge Summary faxed to his primary care
physician regarding this admission and regarding followup on
INR and liver function tests.
The patient was given very explicit instructions to continue
the Lovenox and Coumadin until told to stop by his primary
care physician.
The patient was also reminded to complete his full - at least
4-week - course of antibiotics. All questions about his
diagnosis, his condition, followup, and medications were
answered satisfactorily for the patient.
The patient understood his diagnosis, and need for followup,
and the parameters for returning to the Emergency Department
to [**Hospital6 6640**] or for calling his primary care
physician in the future.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with multiple follow-up
instructions.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 6648**]
Dictated By:[**Doctor First Name 6649**]
MEDQUIST36
D: [**2194-6-7**] 10:39:43
T: [**2194-6-7**] 12:26:30
Job#: [**Job Number 6650**]
cc:[**Telephone/Fax (1) 6651**]
ICD9 Codes: 7907, 4280, 4019, 412 | [
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train_2195 | completed | 248f0692-c96c-4c53-ab17-1fe3d0d2a604 | Medical Text: Admission Date: [**2167-6-22**] Discharge Date: [**2167-7-2**]
Date of Birth: [**2121-1-4**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Levofloxacin / Flagyl
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Chief Complaint: unresponsive
Reason for MICU transfer: need for Narcan gtt
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 805**] is a 46 year old woman with h/o hemorrhagic stroke
with residual spasticity and weakness, seizure disorder,
depression, Hepatitis C, who was brought it by EMS after being
found unresponsive at home.
The patient got in an argument with her mother this morning,
after which she locked herself in her room and took a handful of
pills -- Morphine and a muscle relaxant (patient unsure of
medication name, but is prescribed Flexeril). She states that
she did not expect to wake up and is quite tearful at the time
of interview. She just returned home 4 days prior after being
discharged from [**Hospital 38**] rehab. She states that her mother
[**Name (NI) **] is "the devil" and was trying to find another home for
her because she couldn't take care of her anymore.
Her family found her unresponsive in her room and called EMS.
Narcan 0.4mg x1 was given in the field. Patient woke up
immediately, but then became more responsive again.
In the ED, initial VS were: 98.2 110 130/82 5 100%. Patient was
given Naloxone 0.4mg IV x1, then started on a Naloxone gtt @
0.3mg/hr given that she was still somnolent. Serum tox was
negative, but urine tox was not obtained.
On arrival to the MICU, patient's VS: P 105 BP 136/90 RR 11
O2sat 100%2LNC. The patient is alert and answering questions
appropriately. She is tearful and is wondering why she is still
alive. She notes some mild headache x3 days, but no vision
changes or changes in weakness. Abdominal distension is old per
patient, and she notes having a BM this morning.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath, cough, dyspnea or wheezing. Denies chest
pain, chest pressure, palpitations. Denies diarrhea, dark or
bloody stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. s/p stroke - left parieto-occipital hemorrhagic stroke in
[**9-11**], unclear etiology, s/p craniotomy to evacuate hemorrhage,
secondary herniation syndrome w subfalcine and transtentorial
herniation, bilat Wallerian degeneration syndrome, quadraparesis
with increasing spastic paraparesis worse on R, prox upper &
both lower extremities, s/p Baclofen pump placement
-Evaluated at [**Hospital1 2025**] by Dr [**Last Name (STitle) **] in [**2163**]
-ongoing issues with increasing spasticity
-[**5-15**] was off Baclofen pump and PO
-[**2-15**] on Baclofen PO (no pump), MS Contin, tizanidine
-[**7-18**] only on MS Contin for pain management
-[**12-19**] on Baclofen PO (no pump), MS Contin & IR PRN
2. hyperhomocysteinemia, mildly elevated, no further w/u planned
3. carries psychiatric diagnoses of OCD & depression with
suicidal ideation; patient notes suicidal attempt at age 13, cut
her wrists
4. sickle cell trait
5. Hepatitis C, genotype 3, viral load 799,000 in [**February 2163**], no
plans to treat as transaminases normal, f/u planned in [**2165**]
6. microcytic anemia with normal iron studies
7. restrictive lung disease due to weakened resp muscles
following stroke
8. GI h/o duodenitis, colitis in [**July 2165**], treated with abx
9. Epilepsy, during [**July 2165**] admission (no clear provoking
factor). She has now had about six or so, her mother thinks.
[**Name2 (NI) **] have been in the hospital. She has had two at home: She
will become agitated and non-sensical, with right gaze
deviation, repetitive verbalizations: "help me", "open it", etc.
Her mother says that she has had no generalized seizures at
home.
10. Question of motor neuron disease (primary lateral
sclerosis)raised in prior MRI findings, EMG and nerve conduction
studies [**12-15**] provided no evidence for the diagnosis.
Social History:
Discharged from [**Hospital 38**] rehab [**2167-6-18**], now staying with her
mother. [**Name (NI) **] smoking (smoked prior to stroke in [**2158**]). No alcohol.
Family History:
Arthritis, walks with cane. Father - unknown. [**Name2 (NI) **]-one with
seizures.
Physical Exam:
Admission Physical Exam:
Vitals: P 105 BP 136/90 RR 11 O2sat 100%2LNC
General: Alert, orientedx2 (aware of place, but thought it was
[**2168-6-8**]), no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: firm, distended, bowel sounds present, baclofen pump in
RLQ, some tenderness to palpation in bilateral lower quadrants,
no rebound or guarding
GU: no foley
Ext: 1+ pulses, no clubbing, cyanosis or edema, LE in braces
Neuro: CNII-XII intact, decreased strength in all extremities,
UE contractions
Pertinent Results:
ADMISSION LABS:
[**2167-6-22**] 05:10PM BLOOD WBC-8.3 RBC-4.40 Hgb-11.8* Hct-37.7
MCV-86 MCH-26.9* MCHC-31.4 RDW-15.3 Plt Ct-288
[**2167-6-22**] 05:10PM BLOOD Neuts-71.2* Lymphs-23.1 Monos-2.5 Eos-2.5
Baso-0.7
[**2167-6-22**] 05:10PM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-136
K-4.5 Cl-100 HCO3-28 AnGap-13
[**2167-6-22**] 05:10PM BLOOD Calcium-8.5 Phos-4.5# Mg-1.9
[**2167-6-22**] 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
IMAGING:
-[**2167-6-22**] CXR:
CONCLUSION: Likely early developing pneumonia left base.
.
-[**2167-6-22**] KUB:
IMPRESSION: Significant distention of the stomach. NG tube
should be
considered. No free air.
.
EEG pending
Brief Hospital Course:
discharge exam:
98.1 121/73 86-90
making eye contact, answering basic questions
her pain level is unchanged, [**2165-5-14**]
stable neurological exam
data:
dilantin trough: 10.3
Ms. [**Known lastname 805**] is a 46 year old woman with h/o hemorrhagic stroke
with residual spasticity and weakness, seizure disorder,
depression, Hepatitis C, who was brought it by EMS after being
found unresponsive at home, after a suicide attempt
.
ACTIVE ISSUES:
.
# Acute overdose: Likely due to ingestion of Morphine, +/-
Flexeril. Serum tox was negative. No evidence of active
infection. Her mental status quickly improved on Narcan gtt,
which was d/c'd after the pt woke up. We initially held sedating
medications: morphine, seroquel, flexeril, hydroxyzine; but
later restarted seroquel when pt was highly agitated. She also
received tramadol as substitute for morphine for her chronic leg
pain, but then refused this medication. Currently she is on
morphine 5mg PO q6h.
# Depression/Suicide attempt: Patient ingested morphine and
other pills in a suicidal attempt after an argument with her
mother. She continued to be tearful and extremely upset that she
was still alive, and was refusing medications, radiology, and
blood draws. She was maintained on a 1:1 sitter and suicide
precautions. Psych evaluated her on [**6-23**], and recommended haldol
IV prn as well as inpatient psychiatric hospitalization. She
became agitated and yelled out at RN staffing on [**6-28**] and then
received a dose of oral and then a dose of IV haldol. She will
receive further psychiatric care in the inpatient psych setting.
#Chronic Spasticity/Pain: Managed with baclofen pump as an
outpatient and she is followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24792**], at his
office address on [**Street Address(2) 94477**], [**Location (un) 38**], [**Numeric Identifier 34404**]. His phone number is [**Telephone/Fax (1) 94478**].
The chronic pain service here spoke with Dr. [**Last Name (STitle) 24792**] and agreed
to refill her baclofen pump while she is an inpatient at [**Hospital1 18**]
to avoid having her travel to brain tree as she remains on
suidice precautions. However, intrathecal baclofen not
available until [**7-2**] at the earliest. The chronic pain service
is available to refill her pump at [**Hospital1 18**] if she is hospitalized
at DEAC4. They will perform the refill at her bedside when the
baclofen intrathecal dose is available from the pharmacy in the
next few days. They can be paged by typing OUCH into the paging
directory (Contact has been Dr. [**Last Name (STitle) 94479**] [**Name (STitle) **]). Baclofen 5mg PO
TID started to help diminish spasticity, as plan will be to
increase intraethcal dose when it is refilled.
however, If she does not have baclofen pump refill prior to [**7-10**], then the receiving staff should arrange for her baclofen pump
to be refilled on [**7-10**] or [**7-11**] at Dr.[**Name (NI) 94480**] office.
# Seizure disorder: Neurology followed the patient. At her
last discharge she was sent to rehab on 3 AEDs including
dilantin, keppra, and lacosamide. At discharge she was only
continued only on dilantin for unclear reasons. Given lack of
clinical seizure activity during this admission and no seizure
activity on an EEG here, neurology recommended continuing her
only on the dilantin alone and arranging for outpatient
neurology f/u with her epilepsy specialist upon discharge from
her psych admission.
# Abdominal distension/vomiting: Patient initially p/w firm,
tender abdomen on exam, but no rebound or guarding. Per patient,
this is not new, and she had a BM after admission. She had a KUB
with large gastric bubble, ?pill bezoar, urinary retention may
have contributed to her abd discomfort. This improved and she
had no active complaints of this symptom.
# Urinary retention: Has baseline retention from her h/o CVAs
and is being treated with Flomax as an outpatient. Large dose of
narcotics she took may be contributing as well. Patient refused
Foley placement or straight cath after admission. We continued
Flomax. She underwent straight cath on [**6-25**] with 1400 cc of NS.
She began voiding spontaneously on [**6-26**].
.
#Possible Aspiration: CXR with increased LLL opacity, which
could have represented pneumonia vs pneumonitis due to possible
aspiration event while the patient was unresponsive. Given that
the patient had no fever, elevated WBC count, cough, we held on
treating possible PNA.
CHRONIC ISSUES:
# Seizure disorder: continued dilantin, level 10.3 (trough on
[**6-28**])
TRANSITIONS OF CARE:
[]monitor seizure activity and adjust AEDs as indicated
[]further psychiatric treatment
[]continue treatment of chronic leg pain
[]REFILL BACLOFEN PUMP BEFORE [**7-12**] (pain fellow pager OUCH,
Dr. [**Last Name (STitle) **] will arrange for baclofen pump refill on the DEAC4
floor.
Medications on Admission:
Medications: per [**Hospital 38**] rehab d/c med list on [**2167-6-18**]
Morphine 7.5mg PO q4h
Seroquel 25mg PO q6h prn agitation
Celexa 40mg PO daily
Fosamax 70mg PO qweek
Vitamin C 500mg PO q8h
Oscal D
Flexeril 10mg PO q12h
Heparin 5000units SC BID
Hiprex 1mg PO q12h
Nitrofurantoin 50mg PO q6h
Zyprexa 1.25mg PO q12h
Dilantin 100mg PO q8h
Flomax 0.4mg PO BID
Hydroxyzine 50mg PO q6h prn
Zofran 4mg q6h prn
Vitamin D3 1000units PO daily
Acetaminophen 650mg PO q6h prn
Bisacodyl 10mg PR daily prn
Senna 2tab PO qhs
Colace 100mg PO BID
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
12. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
13. haloperidol 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
14. haloperidol lactate 5 mg/mL Solution Sig: One (1) Injection
[**Hospital1 **] (2 times a day) as needed for severe agitation.
15. morphine 10 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed for pain.
16. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Suicide attempt
Acute encephalopathy
Seizure disorder
Urinary retention
Discharge Condition:
requires assistance with ADLs.
Discharge Instructions:
You were admitted after a suicide attempt. You improved with
reversal of the morphine medication. You were ultimately
discharged to a psychiatric hospital
TRANSITIONS OF CARE:
[]monitor seizure activity and adjust AEDs as indicated
[]further psychiatric treatment
[]continue treatment of chronic leg pain
[]REFILL BACLOFEN PUMP BEFORE [**7-12**] (pain fellow pager OUCH,
Dr. [**Last Name (STitle) **] will arrange for baclofen pump refill on the DEAC4
floor.
Medication Changes
[]baclofen 5mg TID
[]morphine PRN pain
Followup Instructions:
You can be referred back to dr. [**Last Name (STitle) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 24792**], to
determine any adjustments or management of your pain medication.
His address on [**Street Address(2) 65289**], [**Location (un) 38**], [**Numeric Identifier 34404**] His phone
number is [**Telephone/Fax (1) 94478**]
YOU ARE ADVISED TO HAVE OUTPATIENT PSYCHIATRY/PSYCHOLOGY
FOLLOWUP ARRANGED.
PLEASE SCHEDULE VISIT WITH THE PATIENT'S [**Hospital1 18**] NEUROLOGIST UPON
DISCHARGE, to manage your epilepsy
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Office Phone:([**Telephone/Fax (1) 35413**]
Office Fax:([**Telephone/Fax (1) 94481**]
Patient Location:[**Hospital Ward Name 860**] 4 Comprehensive Epilepsy Center
ICD9 Codes: 311 | [
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train_21495 | completed | 0b563acd-9c55-4822-99ac-a0f691e8fd6f | Medical Text: Admission Date: [**2125-1-10**] Discharge Date: [**2125-1-16**]
Date of Birth: [**2061-11-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin Base / Nickel
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
aortic stenosis, dilated ascending aorta
Major Surgical or Invasive Procedure:
Aortic valve replacement (23mm ON-X mechanical), 28mm Gelweave
graft ascending aorta, Cor-Matrix pericardial closure [**2125-1-10**]
History of Present Illness:
This 63 year old white female has a known bicuspid aortic valve
and a history of rheumatic fever. Serial echos have
demonstrated progressive stenosis of the valve and now a dilated
ascending aorta. She has had peripheral edema and increasing
dyspnea with exertion. She was admitted now for operation
having a catheterization in [**2124-11-23**] showing no coronary
disease.
Past Medical History:
Aortic stenosis
h/o rheumatic fever
Hypertension
ypercholesterolemia
hypothyroidism
rt foot fracture (s/p ORIF)
s/p appendectomy
s/p ovarian cyst removal
osteoporosis
Social History:
She is a widow, living alone. Looking for part-time work. She
used to manage medical records for [**Hospital1 1501**]. Does not exercise. She
is a widow, living alone. Sister lives nearby. Tobacco: quit
[**2097**] ETOH: [**2-25**] wine/wk.
Family History:
Both parents died early of alcohol abuse. Brother died of
esophageal cancer. She has two sisters living. Paternal uncle
with sudden cardiac death in his 40's.
Physical Exam:
Pulse: 92
B/P: Right 116/65 Left 116/54
Resp: 18
O2 Sat: 99% RA
Temp:98
Height: 4'6" Weight: 140
General: alert short statured female in NAD
Skin: color pink, skin warm and dry. Rash right chest and neck.
Belly button without erythema or drainage. There is a small
lesion with scab noted. The skin is friable.
HEENT: conjunctiva pink, left eye lower lid droop, left eye skin
tag lower lid. Oropharynx moist, dental bridge, good dentition.
Neck:supple, trachea midline. Chest:clear
Heart: RRR, III/VI SEM, holosystolic. Nl S1-S2 No S3 or S4
Abd: soft, nontender, nondistended. (+)bowel sounds
Extremities: No CCE. No varicosities
Neuro: alert and oriented, mildy anxious, gait steady, gross
FROM
Pulses: Right Left
Radial 2 2
femoral 2 2
PT 2 2
DP 2 2
Carotids No bruits, transmitted cardiac Murmur bilaterally
Pertinent Results:
[**2125-1-15**] 02:57AM BLOOD WBC-7.1 RBC-2.93* Hgb-8.9* Hct-27.3*
MCV-93 MCH-30.4 MCHC-32.6 RDW-13.0 Plt Ct-185
[**2125-1-10**] 01:56PM BLOOD WBC-10.1# RBC-2.46*# Hgb-7.6*# Hct-22.7*#
MCV-92 MCH-30.9 MCHC-33.5 RDW-12.9 Plt Ct-151
[**2125-1-15**] 02:57AM BLOOD PT-16.0* PTT-59.7* INR(PT)-1.5*
[**2125-1-14**] 04:53AM BLOOD PT-14.2* PTT-45.0* INR(PT)-1.3*
[**2125-1-13**] 04:30AM BLOOD PT-13.6* PTT-25.7 INR(PT)-1.3*
[**2125-1-12**] 01:16AM BLOOD PT-15.3* PTT-31.8 INR(PT)-1.4*
[**2125-1-15**] 02:57AM BLOOD Glucose-124* UreaN-21* Creat-0.5 Na-136
K-3.5 Cl-98 HCO3-30 AnGap-12
[**2125-1-10**] 03:45PM BLOOD UreaN-11 Creat-0.4 Na-142 K-4.3 Cl-115*
HCO3-21* AnGap-10
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 88965**]Portable TTE
(Complete) Done [**2125-1-11**] at 7:44:37 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2061-11-20**]
Age (years): 63 F Hgt (in): 56
BP (mm Hg): 120/60 Wgt (lb): 140
HR (bpm): 84 BSA (m2): 1.53 m2
Indication: Aortic valve disease. H/O cardiac surgery. Left
ventricular function. Prosthetic valve function.
ICD-9 Codes: V43.3, 424.1, 428.0
Test Information
Date/Time: [**2125-1-11**] at 07:44 Interpret MD: [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**],
MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2012AW000-0:00 Machine: vivid q
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 51 ml/beat
Left Ventricle - Cardiac Output: 4.29 L/min
Left Ventricle - Cardiac Index: 2.80 >= 2.0 L/min/M2
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.25
Mitral Valve - E Wave deceleration time: 147 ms 140-250 ms
TR Gradient (+ RA = PASP): >= 11 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2124-9-4**].
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately depressed LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTIC VALVE: Mechanical aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
The rhythm appears to be A-V paced. Results were personally
Conclusions
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 30-35%). A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. The right ventricle is not well [**Doctor First Name **] but its
function is probably normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2124-9-4**]
there is now global left ventricular systolic dysfunction which
is new.
Electronically signed by [**First Name8 (NamePattern2) 35980**] [**Name8 (MD) 35981**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2125-1-11**] 18:00
Brief Hospital Course:
As a same day admit she went to the Operating Room where the
aortic valve was replaced and the ascending aorta replaced using
a 23mm ON-X valve and a 28mm gelweave graft. The peicardium was
closed with Cor-matrix as well. She weaned from bypass on Neo
Synephrine in stable condition. She weaned from the ventilator
and pressor support easily. Chest tubes and temporary pacing
wires were removed per protocol. Coumadin was started for the
mechanical valve and Heparin on POD 3.
Heaprain was stopped on POD#6 when her INR was therapeutic at
2.5 and was given 5mg of coumadin.
She developed a junctional rhythm in the 70s postoperatively and
Electrophysiology was consulted. She converted to sinus rhythm
subsequently. She was aggresively diuresed towards her
preoperative weight. Physical Therapy worked with her for
strength and mobility.
On POD #6 she was cleared for discharge to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
[**Last Name (un) 17679**]. Appropriate follow up instructions, medications and
appointments were given.
Medications on Admission:
EZETIMIBE-SIMVASTATIN [VYTORIN 10-40] 10 mg/40 mg Tablet daily
GENTAMICIN - 0.1 % Cream - apply twice daily
HYDROCHLOROTHIAZIDE 25 mg daily
KETOCONAZOLE - 2 % Cream - apply to rash daily
LEVOTHYROXINE 112 mcg daily
LISINOPRIL 40 mg daily
TRIAMCINOLONE ACETONIDE 0.1 % Cream - apply to ears and neck
daily for 7 to 10 days
TYLENOL EXTRA STRENGTH 1000 mg [**Hospital1 **]
CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] Dosage
uncertain
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Hospital1 1559**]
Discharge Diagnosis:
aortic stenosis
bicuspid aortic vaslve
dilated ascending aorta
s/p aortic valve replacement and ascending aortic replacement
hypertension
hypercholesterolemia
s/p appendectomy
h/o rheumatic fever
osteoporosis
s/p hysterectomy
s/p ovarian cystectomy
hypothyroidism
s/p open reduction and internal fixation of right foot fracture
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mech AVR (ON-X)/
Ascending aortic replacement (28 gelweave)
Goal INR 2.5-3.0
First draw [**2125-1-17**]
Results to phone - please arrange coumadin follow up on
discharge from rehab
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2125-2-19**] at 1:15pm
Cardiologist:Dr.[**Last Name (STitle) **] on [**2125-2-9**] at 12:OOPM
Please call to schedule appointments with:
Primary Care: Dr.[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 133**]) in [**3-29**] weeks
Labs: PT/INR for Coumadin ?????? indication Mech AVR (ON-X)/
Ascending aortic replacement (28 gelweave)
Goal INR 2.5-3.0
First draw [**2125-1-17**]
Results to phone - please arraneg coumadin follow up on
discharge from rehab
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2125-1-16**]
ICD9 Codes: 2851, 4019, 2720, 4168, 2449 | [
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train_328 | completed | 98c05f7c-347f-43f6-aee8-a683b4913276 | Medical Text: Admission Date: [**2158-2-1**] Discharge Date: [**2158-2-7**]
Date of Birth: [**2158-2-1**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 30106**] #1, ([**Known lastname 4489**])
is a 1665 gram baby girl, [**Name2 (NI) **] at 31 and 6/7 weeks
gestational age to a 36 year old, Gravida I, Para 0 to 1
mother with prenatal screens blood type B positive, antibody
negative, group B strep positive, hepatitis B surface antigen
negative, RPR nonreactive. [**Hospital 37544**] medical history was
notable for myomectomy for fibroids. There was a normal
amniocentesis for both twins. Twin #2 had a prenatal
ultrasound suggestive of club foot. The prenatal course was
remarkable for spontaneous di/di twinning with concordant
growth and diet controlled gestational diabetes. Prior
preterm labor was treated with Magnesium Sulfate and bed rest
and the mother was betamethasone complete on [**2158-1-3**].
There was premature rupture of membranes nine hours prior to
delivery. Mother received two doses of Terbutaline and was
started on intrapartum Penicillin. A Cesarean section was
performed for malpresentation and changing cervix.
This twin emerged with strong cry and had Apgars of seven and
eight at one and five minutes.
PHYSICAL EXAMINATION: Notable for a weight of 1665 grams
(50th percentile); length 42 cm (50th percentile); head
circumference 30 cm (50th percentile). Examination was
remarkable for a preterm infant in mild to moderate
respiratory distress. Pink color. Soft, anterior fontanel,
normal facies, intact palate. Mild retractions. Coarse
breath sounds with fair air entry. No murmur. Femoral
pulses present. Flat, soft, nontender abdomen without
hepatosplenomegaly. Normal external genitalia. Normal
perfusion. Normal tone and activity.
HOSPITAL COURSE: 1.) Respiratory: Baby had initial
respiratory distress, likely retained lung fluid versus
surfactant deficiency. She was placed on C-Pap of six and
weaned to room air by 24 hours of life. Subsequently, she
has been comfortable in room air, saturating greater than 95
to 97%. She has not had significant apnea of prematurity and
is not on caffeine.
2.) Cardiovascular: [**Known lastname 4489**] has been stable from a
cardiovascular standpoint from admission. No murmurs have
been noted.
3.) Fluids, electrolytes and nutrition: [**Known lastname 4489**] was
initially npo and received D-10 at 80 cc per kg per day
and was transitioned to peripheral parenteral nutrition. She
was started on enteral feeds at around 24 hours of life and
has advanced easily to full enteral feeds at 150 cc per kg
per day. She has been advanced from premature Enfamil 20 to
22 calories per ounce. All her feeds are p.g. At discharge,
her weight was 1,615 grams (down from birth weight of 1665
grams).
4.) Gastrointestinal: No active issues.
5.) Hematology: Maternal blood type was B positive; antibody
negative. Baby's blood type has not been recorded. Maximum
bilirubin was on [**2158-2-4**] at 7.1. No phototherapy was initiated
and the bilirubin was decreased to 6.1 on [**2158-2-6**].
6.) Infectious disease: Initial CBC showed a white count of
12.6 with 5% polys, 85% lymphocytes, 7% monocytes, 0 bands.
Hematocrit was 51. Platelets were 381. Baby was started on
ampicillin and gentamicin which were discontinued at 48
hours, with negative blood cultures. There have been no
other active infectious disease issues.
7.) Neurology: Cranial ultrasound has not yet been performed
but should be done in the next week.
8.) Sensory: Hearing screening has not yet been performed.
Ophthalmology examination has also not yet been performed and
given the gestational age at 31 and 6/7 weeks, this should be
considered in [**3-2**] weeks.
9.) Routine health care maintenance: Newborn state screen
was sent on [**2158-2-4**] with results pending. No immunizations
have been given.
CONDITION AT TRANSFER: Stable.
DISCHARGE DISPOSITION: [**Hospital **] Hospital, Level II Neonatal
Intensive Care Unit.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 52636**] at HVAMPBD.
CARE/RECOMMENDATIONS:
1. Feeds at discharge are premature Enfamil at 22 calories
per ounce, currently advancing on caloric density.
2. Medications: None at this time.
3. Car seat testing has not yet been done but should be done
prior to discharge.
4. State newborn results are pending.
5. Synagis-RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following
three criteria:
1.) [**Month (only) **] at less than 32 weeks.
2.) [**Month (only) **] between 32 and 35 weeks with two of three of the
following: Day care during the RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities, school age siblings.
3.) With chronic lung disease.
Influenza immunization should be considered annually in
the Fall for preterm infants with chronic lung disease
once they reach six months of age. Before this age, the
family and other caregivers should be considered for
immunization against influenza to protect the infant.
FOLLOW-UP APPOINTMENTS: No follow-up appointments have yet
been scheduled.
DISCHARGE DIAGNOSES:
1. Prematurity at 31 and 6/7 weeks gestational age.
2. Mild hyperbilirubinemia.
3. Immature feeding.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Name8 (MD) 52637**]
MEDQUIST36
D: [**2158-2-7**] 08:22
T: [**2158-2-7**] 08:55
JOB#: [**Job Number 52638**]
ICD9 Codes: 7742, V290 | [
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train_1158 | completed | 404354c7-d399-4e82-a134-e3d5b3ec332f | Medical Text: Admission Date: [**2141-4-5**] Discharge Date: [**2141-4-10**]
Date of Birth: [**2094-11-10**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
woman with history of migraine headaches. She had a head CT
and MRI done at an outside hospital which revealed a cerebral
aneurysm. She subsequently underwent a diagnostic angiogram at
[**Hospital1 18**] by Dr. [**Last Name (STitle) 1132**] which revealed 3 aneurysms, 1 of the right
internal carotid artery bifurcation, 1 of the right MCA
bifurcation, and 1 of the left origin of the anterior choroidal
artery.
HOSPITAL COURSE: The patient was admitted and taken to the
OR on [**2140-4-5**] and had a clipping of a right MCA and right ICA
bifurcation aneurysms. Intraoperatively there were no
complications. The patient was transferred to the Intensive Care
Unit for close monitoring where she remained awake, alert,
oriented times three, moving all extremities strongly with no
drift. Her chest was clear to auscultation. Cardiovascular was
regular rate and rhythm, her abdomen as soft, nontender, non
distended. Her extremities were warm. She had positive
pedal pulses and no edema. Her muscle strength was [**4-16**] in
all muscle groups and sensation was intact to light touch.
She was transferred to the regular floor on [**2140-4-6**] in stable
condition. She had a T max of 101.3 on [**2141-4-9**], all cultures
were negative. On [**4-10**] she had been afebrile and was
discharged to home in stable condition with follow-up with
Dr. [**Last Name (STitle) 1132**] in one weeks time.
DISCHARGE MEDICATIONS: Fioricet 1-2 tabs po q 4 hours prn.
Patient was stable at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2141-4-10**] 09:31
T: [**2141-4-10**] 20:32
JOB#: [**Job Number 40852**]
ICD9 Codes: 3051 | [
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train_1223 | completed | bd81ee21-81f3-4259-9e52-9263cf78047f | Medical Text: Admission Date: [**2131-5-18**] Discharge Date: [**2131-5-28**]
Date of Birth: [**2131-5-18**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname **], Twin number one,
was born at 30 and 3/7 weeks gestation to a 44 year old
gravida IX, para 0, now I, woman (spontaneous loss times
eight). The mother's prenatal screens are blood type A
positive, antibody negative, hepatitis B surface antigen
negative. This was a spontaneous twin pregnancy of
monochorionic diamniotic twins. The pregnancy was
complicated by ultrasound diagnosis of ventriculomegaly in
both twins, a normal magnetic resonance imaging, normal
amniocentesis and the condition resolved spontaneously.
Early cervical changes prompted a cervical cerclage placement
at 18 weeks gestation. The mother received a complete course
of Betamethasone at 28 weeks gestation. This twin was noted
to have intrauterine growth restriction and was followed with
serial ultrasounds. A study ten days prior to delivery
showed Baby A at the ninth percentile with increased systolic
to diastolic ratio. Twin B was absent diastolic flow.
Ultrasound on the day prior to delivery showed vertex/breech
presentation. Both fetuses had normal amniotic fluid volume
and absent diastolic flow. The obstetrician recommended
routine fetal testing. Therefore, they returned on the day
of delivery when variable fetal heart rate decelerations were
observed and then the mother was found to be having
contractions.
A decision was made to deliver by cesarean section. This
twin emerged with spontaneous cry, however, did require
continuous positive airway pressure to sustain color. Apgar
seven at one minute and seven at five minutes. The birth
weight was 1150 grams (10 to 25th percentile). The birth
length was 36.5 centimeters (10th to 25th percentile) and the
head circumference was 27.5 centimeters (10th to 25th
percentile).
PHYSICAL EXAMINATION: Admission physical examination reveals
a vigorous nondysmorphic preterm infant. Anterior fontanelle
open, soft and flat. Palate intact. Subcostal and
intercostal retractions, grunting, flaring when CPAP removed.
Diminished breath sounds bilaterally. The heart was regular
rate and rhythm, no murmur. Peripheral pulses present. No
hepatosplenomegaly. Three vessel umbilical cord. Normal
male genitalia for gestational age with testes in scrotum
bilaterally. Normal back and hips. Appropriate tone,
strength and activity.
HOSPITAL COURSE: Respiratory status - The infant required
nasopharyngeal continuous positive airway pressure from soon
after admission until day of life number five when he weaned
to room air where he has remained. On examination, he has
some mild subcostal retractions. Lung sounds are clear and
equal. He was started on Caffeine Citrate on day of life
number two for apnea of prematurity. He remains on that at
the time of transfer.
Cardiovascular status - The infant has remained normotensive
throughout his NICU stay. He does continue to have two to
five episodes of apnea and bradycardia in every 24 hour
period. On examination, he has a heart with regular rate and
rhythm, no murmur.
Fluids, electrolytes and nutrition status - At the time of
transfer, his weight is 1080 grams, his length is 36.5
centimeters and his head circumference is 27 centimeters.
Enteral feeds were begun on day of life number two and
advanced to full volume feedings on day of life number eight
of breast milk, 20 calorie per ounce formula by gavage every
four hours. Total fluids of 150 cc/kg/day. On the day of
discharge, he was tolerating 24 calories per ounce.
Mother plans to breast feed and has been pumping.
Gastrointestinal status - The infant has been treated with
phototherapy since day of life number one. Phototherapy was
discontinued between day of life number five and six, but was
turned on again for a rising bilirubin. The peak bilirubin
was on day of life number eight with total 7.0, direct 0.3.
Phototherapy was discontinued yesterday. A rebound bilirubin
prior to transfer was 4.9/0.2.
Hematology status - The infant received no blood product
transfusions during the NICU stay. His last hematocrit on
day of life number three was 48.8.
Infectious disease status - The infant was started on
Ampicillin and Gentamicin at the time of admission for sepsis
suspected. Antibiotics were discontinued after 48 hours when
the infant was clinically well and the blood cultures
negative.
Neurology - A head ultrasound on [**2131-5-28**] was normal.
Audiology - Hearing screening has not yet been done and is
recommended prior to discharge.
Psychosocial - The parents have been very involved in the
infant's care throughout the NICU stay. The infant is
discharged in good condition.
The infant is transferred to [**Hospital **] Hospital for continuing
care.
The parents have not yet identified a primary pediatric care
provider.
RECOMMENDATIONS AFTER DISCHARGE: Feedings - 24 calorie per
ounce breast milk or formula and to increase calories as
needed for consistent growth. Total fluids 150 cc/kg/day.
Feedings every four hours by gavage.
Medications:
1. Caffeine Citrate 9 mg PG daily.
2. Ferrous Sulfate (25mg/ml) 0.1 ml pg daily.
3. Vitamin E 5 international units pg daily.
The infant has not yet had a car seat position screening
test.
State Newborn Screen was sent on [**2131-5-21**] and [**2131-5-27**].
The infant has not yet had any immunizations.
DISCHARGE DIAGNOSES:
1. Prematurity 30 and 3/7 weeks gestation.
2. Twin number one.
3. Status post mild respiratory distress syndrome.
4. Sepsis ruled out.
5. Hyperbilirubinemia of prematurity.
6. Apnea of prematurity.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2131-5-27**] 04:43:50
T: [**2131-5-27**] 10:27:33
Job#: [**Job Number 10609**]
ICD9 Codes: 769, 7742, V290 | [
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train_1421 | completed | 1678c345-9195-4147-9724-7a309f452227 | Medical Text: Admission Date: [**2166-9-5**] Discharge Date: [**2166-9-15**]
Date of Birth: [**2096-7-26**] Sex: M
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male who was first noted to have bilateral lung masses on a
chest x-ray in preparation for possible sinus surgery. A
follow-up CAT scan of the chest in [**2166-3-26**] originally had
shown a 6.5 cm left upper lobe mass and a 3.5 cm lobulated
right upper lobe mass. He consequently underwent
fluoroscopic biopsy of the right-sided mass which showed
adenocarcinoma. Bronchial biopsy of the left upper lobe
showed poorly differentiated large cell carcinoma with
squamous differentiation. Metastatic work-up of the head,
bone, and abdomen was negative. His laboratory studies
remained relatively normal.
He was seen by the Oncology Service and started on
chemotherapy. The follow-up imaging showed marked regression
of his tumor. He was consequently referred to Thoracic
Surgery for a possible surgical intervention. The patient
has not lost significant weight and has not had any fevers,
headaches, or chest pain. He has had good appetite
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Nasal polyps. 4. Bilateral lung
carcinoma. 5. Chronic maxillary and ethmoid sinusitis. 6.
Peptic ulcer disease.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Hydrochlorothiazide 25 mg q.d., Lipitor 10 mg
q.d., Atrovent, Vanceril, antihistamines for allergies.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: Likely asbestos exposure. History of
smoking (60 pack years).
PHYSICAL EXAMINATION: General: Well-developed, in no
apparent distress. HEENT: Anicteric. No lymphadenopathy
palpated. Lungs: Clear to auscultation bilaterally. Heart:
Regular, rate and rhythm without murmurs. Abdomen: Soft,
nontender, nondistended. Extremities: Pulses present
bilaterally. Warm and well perfused.
LABORATORY DATA: White blood cell count 7.0, hematocrit 38,
platelet count 351; BUN 17, creatinine 0.8, sodium 141,
potassium 3.9, chloride 100, carbon dioxide 28; liver
function tests within normal limits; FEV1 was 44% of the
predicted value.
HOSPITAL COURSE: Given the diagnosis of bilateral lung
cancer, Thoracic Surgery was consulted. On [**2166-9-5**],
the patient underwent median sternotomy, left upper
lobectomy, bronchoscopy, pedicled pericardial flap, right
upper wedge resection, and decortication of the left lung.
The patient tolerated the procedure well, and there were no
immediate complications. Please see the full operative
report for details.
The patient was transferred to the Intensive Care Unit in
fair condition. He had to be reintubated and maintained on
pressure support. He was transfused with 2 U of packed red
blood cells for a hematocrit of 23.6. Chest x-ray obtained
at that time, showed left lower lobe collapse/consolidation
but appeared relatively unchanged. The patient underwent a
series of therapeutic bronchoscopies during his stay in the
Intensive Care Unit. It showed mucous plugging and thick
secretions. He had an increased need of Neo requirement.
The patient was weaned of sedation. His chest x-ray showed
some interval improvement.
He continued to have low-grade fevers. He was placed on
Ceftriaxone and Kefzol. His hematocrit remained stable.
There was some difficulty weaning him off of pressure
support. In addition, his tube feeding was initiated. He
continued to have thick oral secretions. He remained in
sinus rhythm but had an eight-beat run of ventricular
tachycardia was noted. The patient was started on Amiodarone
drip. He was transfused again with one unit of red blood
cells. The patient was successfully extubated on
postoperative day #4.
He was transferred to the red floor on postoperative day #5
in stable condition. He continued to produce good urine. He
remained in sinus rhythm. He continued to be afebrile with
stable blood pressure and heart rate. Physical Therapy was
consulted which recommended rehabilitation facility upon
discharge.
The chest tubes were removed. The patient was discharged to
the rehabilitation facility on [**2166-9-16**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Bilateral lung carcinoma status post medial sternotomy,
left upper lobectomy, bronchoscopy, pedicled pericardial
flap, right upper wedge resection, and decortication of the
left lung.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS: Amiodarone 400 mg q.d. x 1 month,
Ambien 5 mg p.o. h.s., Atenolol 12.5 mg p.o. b.i.d.,
Fluticasone Propionate 110 mcg 2 puffs b.i.d., Keflex 500 mg
q.6 hours p.o. x 7 days, Heparin subcue 5000 U b.i.d. until
sufficiently mobile, Albuterol Ipratropium 1-2 puffs inhalers
q.6 hours p.r.n., Hydrochlorothiazide 25/25 one tab q.d.,
Lipitor 10 mg p.o. q.d., Vanceril.
DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with
his surgeon Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in approximately 1-2 weeks. 2.
The patient is to follow-up with his primary care physician
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**] in approximately 1-2 weeks. 3. The patient
is to follow-up with his oncologist as scheduled (Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 3274**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2166-9-15**] 18:13
T: [**2166-9-15**] 19:35
JOB#: [**Job Number 43211**]
ICD9 Codes: 5185, 2762, 5180, 4271, 2720, 4019 | [
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train_1536 | completed | cd518943-086b-4b1f-bd82-039999dc3bce | Medical Text: Admission Date: [**2111-8-4**] Discharge Date: [**2111-8-9**]
Service: SURGERY
Allergies:
Penicillins / Lyrica
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Right lower extremity rest pain with non-healing right toe ulcer
Major Surgical or Invasive Procedure:
Right femoro-peroneal bypass graft with lesser saphenous vein
graft
History of Present Illness:
This patient is an 85 year old male with a history of severe
coronary artery disease s/p myocardial infarction, congestive
heart failure, hypertension who presents with chronit
unremitting right lower extremity rest pain and a non-healing
right toe ulcer. The patient received an extensive coronary
work-up prior to presentation and was felt to be a poor
operative candidate given his other co-morbidities. This poor
candidate status was discussed at length with the patient and
his family, who remained quite insistent that, despite the high
risks, we procede with a limb-saving intervention
Past Medical History:
CAD,MI ,CHF,HTN,hypercholestremia,DUJd of rt. hip,hx TISs/p left
CEA [**2094**]'s,BPH s/p turn-now w frequency/nocturia
Social History:
Remote history of smoking, quit 40 years ago, social ETOH use.
Physical Exam:
Awake and alert, NAD
RRR w/ SEM at base
Crackles at lung bases on auscultation bilaterally
Abdomen soft, obese, non-tender
Pulse exam: DP/PT dopplerable bilaterally
Brief Hospital Course:
The patient was admitted to the hospital and started on IV
antibiotics to treat his non-healing ulcer. Cultures were taken,
and ultimately grew out gram-positive cocci and gram-negative
rods. He was taken to the operating room on [**8-6**] for a right
femoro-peroneal bypass graft with lesser saphenous vein. The
patient initially tolerated this procedure well and was taken to
the vascular surgery ICU for recovery. On the morning of
post-operative day #2, the patient began to complain of chest
pain and was found to have a systolic blood pressure of 85 with
elevated pulmonary artery pressures of 60/30. This picture was
concerning for an active coronary event. The patient was
immediately transferred to the cardiovascular surgery ICU for
further monitoring and treatment. An electrocardiogram showed
new lateral precordial ST-segment elevation. Troponins were
checked and were found to be rising to 0.67. At 2:30am on
post-operative day #3, the patient was found to be tachypnic and
tachcardic. Lasix was given emperically, however, soon after the
patient became unresponsive and asystolic. ACLS protocol was
initiated and the patient was coded for 30 minutes without
return of cardiac function. The patient was pronounced deceased
at 3:57am.
Medications on Admission:
lasix 80mgm qam,lasix 40mgm qpm,plavix 75mgm',kcl
20meq",atorvastatin 40mgm',lopressor25mgm"percoset
Discharge Disposition:
Expired
Discharge Diagnosis:
Coronary artery disease, s/p myocardial infarction
Peripheral vascular disease
Congestive heart failure
Hypercholesterolemia
Benign prostatic hyperplasia
Carotid stenosis s/p carotid endarterectomy
Discharge Condition:
Expired
ICD9 Codes: 4280, 4241, 412, 4439, 2720 | [
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train_1678 | completed | 258f6f6e-9450-496e-9ce5-bbfac99c7a0a | Medical Text: Admission Date: [**2189-5-18**] Discharge Date: [**2189-5-27**]
Service: Cardiac Surgery
CHIEF COMPLAINT: Syncopal episodes.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 33754**] is a 78-year-old
male with a known history of aortic stenosis, non-insulin
dependent diabetes mellitus and hypertension who was
transferred from an outside hospital for cardiac
catheterization. They evaluated aortic stenosis after he
sustained a syncopal episode while driving. He was admitted
under the medical team for a cardiac catheterization.
PAST MEDICAL HISTORY: Aortic stenosis, asbestosis,
non-insulin dependent diabetes mellitus, hypertension,
arthritis.
PAST SURGICAL HISTORY: Status post appendectomy.
ALLERGIES: None known.
MEDICATIONS: On admission, Glyburide 5 mg q d, Prednisone 5
mg q d, Albuterol, Lisinopril 2.5 mg q d, Protonix 40 mg q d,
Aspirin 81 mg q d.
HOSPITAL COURSE: The patient was admitted on the cardiac
medicine service and [**Known lastname 1834**] a cardiac catheterization
which revealed severe three vessel disease and mild aortic
stenosis. Cardiac surgery was consulted at this point and
the decision to take him to the operating room was made. Mr.
[**Known lastname 33754**] [**Last Name (Titles) 1834**] a CABG times three on [**2189-5-21**] with LIMA to
LAD, RSVG to right RCA PD, RSVG to ramus. He tolerated the
procedure well and was taken to the CSRU in a stable
condition, intubated and on intra-aortic balloon pump. He
was slowly weaned off his pressors and extubated on
postoperative day #1. His chest tubes were discontinued on
postoperative day #2. On postoperative day #3 he was
considered stable for transfer to the floor. His subsequent
hospital stay was uneventful. His pacing wires were
discontinued on postoperative day #4. He was ambulated to a
level V and was ready for discharge on postoperative day #6.
Pain was well controlled with po analgesics and his chest
incision was healing well.
DISCHARGE MEDICATIONS: Lasix 20 mg q d times one week, KCL
20 mEq q d times one week, Colace 100 mg [**Hospital1 **], Aspirin,
enteric coated 325 mg q d, Glyburide 5 mg q d, Protonix 40 mg
q d, Amiodarone 400 mg q d times one month, Lopressor 25 mg
[**Hospital1 **], Percocet 1-2 tablets q 4-6 hours prn, Prednisone 5 mg q
d, Albuterol inhaler.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2189-6-4**] 16:13
T: [**2189-6-5**] 09:01
JOB#: [**Job Number **]
ICD9 Codes: 4111, 4241, 4019 | [
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train_1726 | completed | 9164d918-9682-4ba1-bea6-0b76c5bbaf5b | Medical Text: Admission Date: [**2125-9-7**] Discharge Date: [**2125-9-10**]
Date of Birth: [**2050-1-19**] Sex: M
Service: CCU/MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 75 year-old male with
a history of diabetes, coronary artery disease. He is status
post a silent myocardial infarction and also has a history of
chronic obstructive pulmonary disease (he has 100 pack year
of smoking tobacco and is still smoking). He also has a
history of hypercholesterolemia, hypertension. He also has a
history of lower gastrointestinal bleed and anemia. The
patient presented to the [**Hospital 882**] Hospital on [**2125-9-7**]
with shortness of breath and diaphoresis. He was found to
have an ST segment elevation myocardial infarction and
congestive heart failure at the [**Hospital1 882**] and was transferred
to the [**Hospital1 69**] for cardiac
catheterization. In the catheterization laboratory revealed
three vessel disease, 100% left anterior descending coronary
artery and right coronary artery, short left main carotid
artery without any lesions, and an 80% left circumflex artery
and an 80% OMI. There were no interventions done during the
catheterization. Many collaterals were noted at the time.
CT Surgery was consulted in the catheterization laboratory
during the procedure for a potential coronary artery bypass
graft. The patient's catheterization was uncomplicated and
he was scheduled to undergo coronary artery bypass graft on
Monday [**2125-9-10**].
In preparation preoperatively he had an echocardiogram, which
showed an ejection fraction of 15 to 20% and apical inferior
and basal akinesis. This was in contrast to his
transthoracic echocardiogram study in [**2124-5-5**] that
showed an ejection fraction of 50%, mild hypokinesis of the
inferobasal wall. The patient was also noted post
catheterization to have a mild groin hematoma. Further
preoperative evaluation included diuresis with Lasix as well
as carotid doppler ultrasound studies, which demonstrated 60%
occlusion in the left carotid artery and essentially clean
right carotid artery. The patient was stable throughout his
course of his hospitalization until the morning of [**2125-9-10**] when the house staff was called for an expanding
hematoma of the right groin. Initially his vital signs were
stable. Repeat hematocrit showed that this was stable since
the prior study four hours earlier.
Over the next couple of minutes the patient's blood pressure
was noticed to drop from the systolic high 110s to 80/40.
The patient was given wide open fluids and a code was called
and eventually Dopamine was started. The patient's blood
pressure responded to this intervention. During the code a
unit of packed red blood cells was ordered and begun to
transfuse. Shortly after this time the patient was noted to
seize briefly and then go into ventricular fibrillation
rhythm. The patient was shocked repeatedly for ventricular
fibrillation. He subsequently went in and out of asystole
alternating with ventricular fibrillation. The patient had
over the course of the one hour code received multiple
shocks, calcium carbonate, bicarbonate, magnesium, amiodarone
as well as atropine. None of these measures were sufficient
to sustain life and the patient expired at approximately 1:05
p.m. on [**2125-9-10**]. The family, which included his two
sisters [**Name (NI) **] and [**First Name8 (NamePattern2) 1743**] [**Name (NI) 12163**] were notified in a timely
fashion and they refused the postmortem examination.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Doctor Last Name 25109**]
MEDQUIST36
D: [**2125-9-10**] 15:28
T: [**2125-9-13**] 13:33
JOB#: [**Job Number 25110**]
ICD9 Codes: 496, 4019 | [
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train_3206 | completed | 48bb672b-39ee-41bf-87ba-5098d9a8890f | Medical Text: Admission Date: [**2155-7-9**] Discharge Date: [**2155-7-14**]
Date of Birth: Sex: F
Service: Medicine
DISPOSITION: [**Hospital3 **] Center
CHIEF COMPLAINT: The patient was admitted to the Medical
Intensive Care Unit Service on [**7-9**] and then was admitted
onto the General Medicine Service on [**7-12**]. She was
admitted with a chief complaint of gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
woman with a history of chronic lymphocytic leukemia,
prolymphocytic leukemia type, pulmonary hypertension who
presents with epistaxis to the Emergency Department. She was
noted to be hypoxic with oxygen saturations in the 70s. A
chest x-ray was done that showed bilateral pleural effusions
and some concern for aspiration versus congestive heart
failure. The epistaxis was controlled with Gelfoam. At this
point the patient complained of laying on something wet in
the Emergency Department. She was noted to be sitting in a
pool of bright red blood. Her hematocrit decreased from 33
at 1 PM to
[**Name8 (MD) 34268**], M.D.
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2155-7-13**] 14:29
T: [**2155-7-13**] 16:26
JOB#: [**Job Number 34269**]
cc:[**Hospital3 34270**]
ICD9 Codes: 5789, 4280, 4019 | [
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