messages
listlengths 2
2
|
|---|
[
{
"content": "Briefly this 68 year old male with a history of coronary artery disease diabetes mellitus peripheral vascular disease was admitted originally to the Podiatry Service for a left patellar mid-foot ulcer . He underwent angiogram on 2013-08-28 to evaluate his circulation and found at that time that the patient had a poor circulation to the left leg . The patient was transferred to the Vascular Surgery Service for bilateral iliac stenting at that time . The patient also at that time was followed by Cardiology and for preoperative evaluation had a stress test which was positive and he became diaphoretic but denied any chest pain . Atropine was given and heart rate returned to the 70s and his blood pressure returned to the 120s over 80s . The patient denied any orthopnea shortness of breath chest pain paroxysmal nocturnal dyspnea or cough . He had occasional leg swelling . PAST MEDICAL HISTORY 1 . Coronary artery disease status post myocardial infarction in 2006 and 1997 and status post percutaneous transluminal coronary angioplasty times two . Diabetes mellitus type 2 since age 25 now currently on insulin which is complicated by peripheral neuropathy nephropathy and Charcot s foot . Chronic renal insufficiency . Peripheral vascular disease status post left iliac stent and right femoral stent . Hypertension . High cholesterol . Question of tendonitis . MEDICATIONS ON ADMISSION 1. Insulin 70 30 40 units q. a.m. and 40 units q. p.m. 2. Diovan 160 mg p.o. q. day . Nortriptyline 25",
"role": "user"
},
{
"content": " mg p.o. q. h.s. Norvasc 10 mg p.o. q. day . 5. Metoprolol 50 mg p.o. twice a day . 6. Hydrochlorothiazide 15 mg p.o. q. day . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Respiratory On admission the patient had what appeared to be acute respiratory distress syndrome secondary to community acquired pneumonia .', 'She was maintained on a ventilator and ventilated according to ARDSNet protocol . For antibiotic coverage of her pneumonia",
"role": "user"
},
{
"content": " she was started on Levaquin ceftriaxone and vancomycin .', 'Over the next two days after admission the patient s vent settings were gradually weaned and she was extubated two days after being transferred to this hospital .', 'After extubation the patient was oxygenating well on face mask . She did continue to have a persistent fairly severe cough however her cough was weak due to abdominal muscle pain from repeated coughing .', 'The cough was mostly nonproductive . The patient was breathing comfortably . As there was no identified bacterial pathogen on any cultures', 'the patient was continued on the triple antibiotics for first several days of the hospitalization . She was also on round-the-clock Atrovent and albuterol nebulizers .', 'Once the patient was transferred out of the ICU and after extubation the antibiotics were gradually narrowed . The vancomycin and Levaquin were discontinued after approximately four days in the hospital .', 'The ceftriaxone was discontinued after four days in the hospital and the patient was to continue on Levaquin . The patient had gradual improvement in her oxygenation .', 'Pain control The patient had fairly significant abdominal pain secondary to persistent cough . She was started on a regimen of MS Contin with oxycodone for breakthrough pain .', 'This helped her somewhat though she has continued to have difficulty coughing due to the pain . Tylenol and ibuprofen were also added for better control .', 'Transaminitis The patient was noted to have mild transaminitis on admission . However this was felt to be due to her significant infection .', 'This should continue to be followed as an outpatient to assure that it returns back to normal . Anemia The patient s reticulocyte count showed inadequate production .', 'Iron studies showed a mixed picture with decreased iron and decreased iron to TIBC ratio suggestive of iron-deficiency anemia but also normal to high MCV .', 'B12 was noted to be low and the patient was given an injection of IM B12 while in the hospital .', 'She was also started on iron supplementation . Hypothyroidism The patient was continued on Synthroid for her chronic hypothyroidism . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Prilosec 20 mg p.o. q.d. Percocet 1-2 tabs p.o. q.6-8h. x5 days MVI 1 tab p.o. q.d. DISCHARGE FOLLOW-UP The patient was advised to follow-up with Dr. Edwards in clinic in one week . CONDITION ON DISCHARGE Stable condition . DISCHARGE DISPOSITION The patient was discharged to home . Dictated By SON RHALT SUBINTERN",
"role": "user"
},
{
"content": " . Attending MOPAIGEIT S. SOLID M.D. KP91 KX681 6848 Batch 52108 Index No. GAEHS07465 D 03 01 00 T 03 01 00 CC 1. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is thus stage IV endometrial and stage III-C",
"role": "user"
},
{
"content": " ovarian vs metastatic endometrial for line II cycle I chemotherapy IFEX MESNA and VP-16 . The plan was for urinalysis q d . With the history of DVT we plan Coumadin and check her coags . The patient was tachycardiac on admission and it was felt she was dehydrated and or anxious at the time of her initial evaluation . EKG showed sinus tachycardia and incomplete right bundle branch block . When compared with ECG of 11-06-90 there was borderline criteria for anterior MI although the patient denied any chest pain at any point . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Non-insulin-requiring diabetes mellitus and hypercholesterolemia . PAST SURGICAL HISTORY",
"role": "user"
},
{
"content": " As given above . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Non contributory and unavailable as she is adopted . PHYSICAL EXAMINATION She is an obese elderly woman in no acute distress . vital signs 158 60 with a heart rate of 85 temperature 99.7 respirations 14 . Her neck showed no JVD . Lungs clear to auscultation . Her abdomen was obese and distended with good bowel sounds large ventral hernia . Colostomy with black stool . She had some mid epigastric tenderness and no rebound . Her heart showed a regular rate and rhythm with an S1-S2 no murmur . Her neurological exam was alert and oriented . She had 5 out of 5 strength bilaterally and",
"role": "user"
},
{
"content": " her toes were downgoing . She had no evidence of asterixis . Her skin looked very bronze and tan especially in the sun exposed areas . She had no spider angiomata no palmar erythema no xanthomas and no caput medusae . She did not look teric . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted and pancultured . He was treated",
"role": "user"
},
{
"content": " with vancomycin and ceftazidime while awaiting wound cultures . He had dressing changes twice a day . Surgery was consulted and followed him while he was in house . Cyclosporin levels were followed and his sugars were followed with a sliding scale . During the first two days he required 14 and 22 units of additional coverage . However by day three he required no additional insulin coverage . On the day prior to discharge his intravenous antibiotics were discontinued and he was begun on tetracycline . DISPOSITION The patient was discharged home in stable condition . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Feedings at discharge Similac 22 calories per ounce by mouth ad lib with a goal of decreasing to 20 calories per ounce for dextrose sticks of greater than 60 . Medications None .', 'A state newborn screen was sent",
"role": "user"
},
{
"content": " on day of life three the results are pending . Received hepatitis B vaccine on 2012-09-30 . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Thromboembolus to the right profunda femoris and right superficial femoral artery . MA JAMTLANDBRANTESSLIGH M.D. DICTATING FOR COR TLAND M.D. TR qa bmot DD 07",
"role": "user"
},
{
"content": " 02 92 TD <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was taken from the emergency room and transferred to the Surgical Intensive Care Unit for airway observation . He was given three liters of",
"role": "user"
},
{
"content": " IV hydration with good urine output response . His wounds were dressed with antiointment and Xeroform with the plan to take him to the operating room for debridement under general anesthesia and application of artificial skin . The patient remained hemodynamically stable with good urine output . While in the Intensive Care Unit the patient was put on delirium tremons prophylaxis with Serax around the clock . There was no evidence while in the hospital . The patient was taken to the operating room on 1 5 97 . At that time the patient underwent debridement of his facial wounds and debridement of his right hand and forearm with application of artificial skin which is the dermagraft TC . The patient tolerated the procedure well . There were no complications . Postoperatively the patient was transferred out of the Intensive Care Unit to the burn floor where he received dressing changes p.r.n. The patient remained afebrile and other vital signs were within normal limits . On the day of discharge the patient &aposs dressing was taken down completely and evaluation of the derma graft was made . At that time it appeared well adhered to the underlying skin . There was no evidence of infection . The patient was screened by the rehabilitation facility and felt to be an acceptable candidate . The patient and his family agreed to transfer from Nimaconwood Valley Hospital to Ianehutche Medical Center . DISPOSITION <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Hydralazine 10 mgs PO t.i.d. Digoxin 0.125 mgs PO q.d. thiamine 100 mgs PO q.d. multi-vitamin 1 tab. PO q.d. Peri Colace 100 mgs PO t.i.d. folate 1 mg PO q.d. Norvasc 2.5 mgs PO q. HS Ritalin 10 mgs PO b.i.d. Trazodone 25 mgs PO q. HS Nafcillin 2 gramsIV q.4H which wil",
"role": "user"
},
{
"content": " conclude at the end of the day on 1 16 98 Atroventnebulizer PRN Albuterol nebulizer PRN Tylenol 650 mgs PO q.4H PRN pain . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "RTA diagnosed at",
"role": "user"
},
{
"content": " 14 months of age she had a history of scarlet fever at 14 months of age She also had a recent exposure to varicella . Her brother had developed the typical rash on 9 3 93 <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient had",
"role": "user"
},
{
"content": " no home medications . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Cerebrovascular accident Atrial fibrillation on Coumadin . Diabetes mellitus type 2",
"role": "user"
},
{
"content": " Hypothyroidism . Mild dementia Proteinuria . Nephropathy Anemia . Hearing impaired PAST SURGICAL HISTORY Laparoscopic cholecystectomy as above Total hip replacement in 2002 . Appendectomy Diskectomy . MEDICATIONS ON ADMISSION 1 Digoxin .125 mg qod .25 mg qod . Colace 100 mg po tid Levoxyl 100 ugm po qd Prinivil 20 mg po qd . Zantac 150 mg po bid Aspirin 325 mg qd Aricept 5 mg po qd . Glyburide 1.25 mg po qam Oxybutynin 5 mg po bid . Coumadin 7.5 mg on Sun Tues Wed Fri and Sat 5 mg on Mon and Thurs . ALLERGIES Fluoroquinolones <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Thromboembolus to the right profunda femoris and right superficial femoral artery . MA JAMTLANDBRANTESSLIGH",
"role": "user"
},
{
"content": " M.D. DICTATING FOR COR TLAND M.D. TR qa bmot DD 07 02 92 TD <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Toprol",
"role": "user"
},
{
"content": " . Lasix . Digoxin . Coumadin . Flovent . Albuterol . Lisinopril . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Slow-Mag 2 tablets PO bid Ativan 1 mg sublingually q4h prn nausea . GUABENFRANDA D. PO",
"role": "user"
},
{
"content": " M.D. TR ff bmot DD 06-07-93 TD <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Atenolol 50 mg p.o. q.d. Lipitor 10 mg p.o. q.d. baby aspirin 81 mg p.o. q.d. iron sulfate 81 mg p.o. q.d Lasix 40 mg p.o. q.d. Accupril 40 mg p.o. q.d. hydrochlorothiazide 12.5 mg p.o. q.d. NPH insulin 18 units q.a.m. and 10 units q.p.m. Humalog sliding-scale q.a.m. and q.p.m. PHYSICAL EXAMINATION ON PRESENTATION The patient had a temperature of 100.9 . He had a blood pressure of 148 to 162 45 to 54 . He had a heart rate of 85 to 87 breathing at 17 to 23 satting 100 on room air . In general he was alert and in no acute distress . His neck was supple without any jugular venous distention . HEENT examination revealed his pupils were equal round and reactive to light . His extraocular movements were intact . His sclerae were anicteric . His mucous membranes were moist . His oropharynx was benign . Cardiovascular revealed a regular rate and rhythm heart sounds muffled no murmurs . Respiratory revealed bibasilar rales . Abdomen was soft nontender and nondistended positive bowel sounds . Extremities revealed trace lower extremity edema right greater than left 2 dorsalis pedis and posterior tibialis pulses . He had 2 femoral pulses bilaterally . No hematomas were noted but a soft right femoral bruit was heard . LABORATORY DATA ON PRESENTATION The patient had a white blood cell count of 9.5 a hematocrit of 34.5 a platelet count of 194 . His Chem-7 revealed sodium of 132 potassium of 43 chloride of 97 bicarbonate of 28 BUN of 25 creatinine of 1.3 glucose of 220 . He had an INR of 1.1 . A calcium of 8.4 phosphate of 2.5 magnesium of 1.9",
"role": "user"
},
{
"content": " . Pericardial fluid analysis was consistent with an exudative etiology . RADIOLOGY IMAGING The patient had an electrocardiogram with normal sinus rhythm at 70 normal axis normal intervals low voltage in the limb leads . Chest x-ray on admission revealed a large left pleural effusion . The patient had an echocardiogram on 11-10 which revealed the following Global left ventricular systolic function appeared grossly preserved . Due to technical quality a focal wall motion abnormality could not be fully excluded . The aortic valve leaflets were mildly thickened . The mitral valve leaflets were mildly thickened . There was a large pericardial effusion up to greater than 6 cm wide anterior to the right ventricle . The right ventricle was compressed . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Oxycontin Percocet Paxil Gabapentin Atenolol Discharge Disposition Extended Care Discharge Diagnosis benzodiazipine overdose Discharge Condition stable Discharge Instructions please take your medications and call",
"role": "user"
},
{
"content": " your doctor if you experience chest pain abdominal pain or shortness of breath or any thoughts of hurting yourself or anyone else . Followup Instructions please call your primary doctor Edmund Starke once your are discharge from the hospital Clemmie Shawn MD 65-948 Completed by Michael Melvin Kinzer MD 51-991 2012-03-26 1709 Signed electronically by DR. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "He is to follow up",
"role": "user"
},
{
"content": " with Dr. Rach Breutznedeaisscarvwierst in Clinic. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is an 81 year old female with a history of cerebrovascular accident atrial fibrillation hypothyroidism and dementia who is status post laparoscopic cholecystectomy one week ago who currently presents with a 4 day history of no bowel movement . She has complaints of abdominal distention emesis and constipation . She has no chest pain shortness of breath or fever . She has no nausea or vomiting chills dysuria hematochezia or melena . She was discharged from the hospital on 11 28 02 to a short term rehabilitation facility . She was found to have normal bowel sounds . She presented to the Ponta itri University Medical",
"role": "user"
},
{
"content": " Center Emergency Department on 12 01 02 for evaluation of this constipation . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "NC Physical Exam upon tx to medicine service T 99.0 BP 142 61 Pulse 65 Resp 20 O2 sat 96 RA Gen Alert no acute distress HEENT mucous membranes slightly dry Neck no JVD no cervical lymphadenopathy Chest CTA b l with good air entry CV Normal S1 S2 irreg irreg Abd Soft nontender mild distension normoactive bowel sounds Extr No edema . 2 DP pulses bilaterally Neur A & O X3 dysarthric speech CN mild left facial droop o w appears intact 4 5 strength on flex at elbows b l legs 06-22 strength DTR s intact sensation intact Skin No rash Pertinent Results ERCP report Four fluoroscopic images and ERCP are provided . A large filling defect is seen in the distal duct representing a stone . The common duct is dilated . Subsequent biliary stent was placed after the removal of the stone . Blood cultures 2019-02-01 4 of 4 bottles E.coli CXR Pulmonary edema . ECHO The left atrium is markedly dilated . There is mild symmetric left ventricular hypertrophy . The left ventricular cavity is moderately dilated . There is moderate global left ventricular hypokinesis . Overall left ventricular systolic function is moderately depressed . Right ventricular chamber size and free wall motion are normal . Right ventricular systolic function is normal . Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation . The aortic valve leaflets 3 are mildly thickened . There is no aortic valve stenosis . Mild 1 aortic regurgitation is seen . A bileaflet mitral valve prosthesis is present . The transmitral gradient is normal for this prosthesis . No mitral regurgitation is seen . Mild 1 mitral regurgitation is seen . Due to acoustic shadowing the severity of mitral regurgitation may be significantly UNDERestimated . The tricuspid valve leaflets are mildly thickened . Moderate 2 tricuspid regurgitation is seen . There is mild pulmonary artery systolic hypertension . There is no pericardial effusion . Labs on admission 2019 -02-01 0320 PM BLOOD WBC 11.7 RBC 4.72 Hgb 14.1 Hct 42.7 MCV 91 MCH 29.9 MCHC 33.1 RDW 14.9 Plt Ct 91 2019-02-01 0320 PM BLOOD Neuts 94.6 Bands 0 Lymphs 2.7 Monos 1.9 Eos 0.4 Baso 0.4 2019-02-01 0320 PM BLOOD PT 28.0 PTT 26.7 INRPT 2.9 2019-02-01 0320 PM BLOOD Glucose 202 UreaN 31 Creat 1.3 Na 141 K 4.0 Cl 102 HCO3 27 AnGap 16 2019-02-01 0320 PM BLOOD ALT 167 AST 218 AlkPhos 108 Amylase 117 TotBili 3.6 2019-02-02 0354 PM BLOOD Lipase 992 2019-02-01 0320 PM BLOOD Albumin 4.8 Calcium 9.4 Phos 1.9 Mg 2.0 2019-02-01 0415 PM BLOOD Digoxin 0.3 2019-02-01 1143 PM BLOOD Type ART Temp 38.3 PEEP 5 pO2 115 pCO2 36 pH 7.33 calTCO2 20 Base XS -6 Intubat INTUBATED 2019 -02-01 0406 PM BLOOD Lactate 3.4 2019-02-01 0800 PM BLOOD Lactate 6.4 Labs on discharge 2019-02-06 0630 AM BLOOD WBC 7.4 RBC 3.82 Hgb 11.3 Hct 34.7 MCV 91 MCH 29.5 MCHC 32.5 RDW 15.1 Plt Ct 92 2019-02-09 0445 AM BLOOD PT 19.6 PTT 74.9 INRPT 1.9 2019-02-07 0900 AM BLOOD Glucose 124 UreaN 26 Creat 1.2 Na 140 K 3.7 Cl 102 HCO3 29 AnGap 13 2019-02-07 0900 AM BLOOD ALT 62 AST 45 AlkPhos 105 TotBili 2.2 2019-02-04 0240 AM BLOOD Lipase 74 2019-02-07 0900 AM BLOOD Mg 2.0 2019-02-04 0250 AM BLOOD Lactate 1.0 Brief Hospital Course Pt is a 78 yo male with atrial fibrillation s p multiple CVA s CHF HTN DM2 transferred from the CMED CCU s p intervention for cholangitis . Acute cholangitis Pt was admitted to the ICU intubated and ERCP performed likely stone obstructing CBD . Stent was placed and patient was treated with antibiotics Zosyn > Ciprofloxacin . Per ERCP fellow plan is for patient to return in four weeks to see Dr. Suzanne Davis at which time",
"role": "user"
},
{
"content": " he will likely have repeat cholangiogram and removal of stent and stone . If this is still problematic pt may also need a sphincterotomy . Dr. Demby secretary will contact patient at home the week after discharge to schedule this for the end of January . Pt is to continue ciprofloxacin for a complete 14 day course . 2 Mechanical mitral valve Anticoagulation was reversed for ERCP . After this he was anticoagulated with heparin drip . INR was 1.9 on discharge . He was given sc lovenox x 1 and will continue this the day after discharge bid for one day . VNA will check his INR at home and page his PCP with the results . 3 Atrial fibrillation Rate controlled and on warfarin . While in the hospital he had several episodes of pauses none longer than 2.5 seconds . His digoxin was held and his metoprolol was titrated down from his home dose . Once the digoxin was no longer having effect metoprolol was titrated back to home dose . CHF Pt was oxygen dependent for most of the hospital course CXR was consistent with pulmonary edema . He was diuresed with lasix with good effect . Volume overload likely ocurred in the setting of IV fluids given in the ICU . Did not require lasix on discharge . 5 E. coli bacteremia sepsis Source of acute cholangitis as above . Pt required 3 day stay in the surgical ICU and intubation as above . Intubation Pt was 97 on room air on arrival to Cindy developed rapid ventricular reponse to a fib which was treated but after that period of time required oxygen presumably for pulmonary edema . In the Lori pt was given 3L NS as well as 1 unit of FFP and oxygen requirements contimued to climb . In the CMED CCU pt was intubated for ERCP procedure . He was extubated the next morning . Medications on Admission Lisinopril 2.5 qday Buspiron 20 mg po qday Digoxin Doxasozin 8 mg qhs Glyburide 2.5 mg qday metoprolol bid atorvastatin 20 mg qday warfarin 5 mg qday Discharge Medications 1. Ciprofloxacin 500 mg Tablet Sig One 1 Tablet PO Q12H every 12 hours for 6 days . Disp 12 Tablet s Refills 0 2. Medications Continue all other home medications EXCEPT do not take digoxin . Discharge Disposition Home with Service Discharge Diagnosis Primary diagnosis acute cholangitis Secondary diagnosis anticoagulation with a mechanical valve Atrial fibrillation Diabetes Mellitus Congestive heart failure Discharge Condition stable will work with home PT Discharge Instructions Please continue Ciprofloxacin antibiotic until 2019-02-14 . Dr. Mcfarlane is the doctor who performed the procedure to place a stent in your bile duct a tube that drains the liver . His nurse is going to contact you at home to schedule a time for a repeat procedure to remove that stent . You will have your blood drawn tomorrow 2019-02-10 by VNA . It will be called in to Dr. Hamasaki office and he will call you to see how to change your coumadin . You will also take lovenox subcutaneous injections tomorrow 2019-02-10 . You will take one if the morning and one at night . Continue all of your medications except for digoxin . Followup Instructions Dr. Mcfarlane is the doctor who performed the procedure to place a stent in your bile duct a tube that drains the liver . His nurse is going to contact you at home to schedule a time for a repeat procedure to remove that stent . Before you have the procedure with Dr. Morris you will need to talk to Dr. Moya to see if you need to stop your coumadin warfarin for a few days . Shirley Anthony MD 56-333 Completed by Donald Beverly MD 74-194 2019-02-09 1644 Signed electronically by DR. Shirley V Usher on SAT 2019-02-09 <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "On 2010-06-07 the patient underwent a mechanical aortic valve replacement with a 23 mm Carbomedics mechanical valve and a Supra coronary aortic graft with gelweave 28 mm . The patient tolerated the procedure well with a bypass time of 155 minutes and a crossclamp time of 130 minutes and a rest time of 16 minutes . The patient s pericardium was left open lines placed included a right radial line and a right IJ line both ventricular and atrial wires were placed two mediastinal tubes were placed . The patient was subsequently transferred to the Cardiac Surgery Recovery Unit intubated for further evaluation and management . On transfer the patient s mean arterial pressure was 76 CVP 12 PAD 17 and his Bennie was 25 . The patient was AV paced at a rate of 88 beats per minute . Active drips included milrinone Levophed propofol and insulin . On postoperative day number one the patient was successfully weaned and extubated without complication . The patient was then advanced to oral intake which he tolerated without complication . On postoperative day number two the patient s chest tubes were removed without complication and the patient was subsequently cleared for transfer to the floor . The patient was subsequently admitted to the cardiothoracic service under the direction of Dr. Brenda Hummer . Postoperatively the patient s clinical course was largely unremarkable . The patient was evaluated by Physical Therapy who declared him a suitable candidate for discharge directly to home following resolution of his medical therapy . The patient was advanced to a full regular diet which he tolerated without complication and had adequate pain control provided via oral pain medications . The patient was begun on anticoagulation therapy for a target INR of 2.5 . On the evening of postoperative day number four the patient had a transient",
"role": "user"
},
{
"content": " episode of disorientation and confusion which subsequently resolved spontaneously . By postoperative day number five the patient was noted to be afebrile and stable . His incision was noted to be clean dry and intact with no evidence of cellulitis or purulent drainage . The patient was noted to be independently ambulatory and was productive of adequate amounts of urine . The patient was tolerant of a full regular diet and had his pain well controlled via oral pain medications . The patient s INR was noted to be 2.3 . The patient was subsequently cleared for discharge to home with instructions for follow-up on postoperative day number five 2010-06-12 . CONDITION AT DISCHARGE The patient is to be discharged to home with instructions for follow-up . STATUS AT DISCHARGE Stable . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "On admission vital signs Temperature 101.4 blood pressure 101 62 pulse 80 respiratory rate 19 on a ventilator with settings of assist control at 500 12 and a PEEP",
"role": "user"
},
{
"content": " of 5 . General The patient is intubated and sedated but easily arousable . HEENT Pupils equally round and reactive to light . Sclerae are anicteric . ET tube is in place . Neck Soft and supple . Cardiovascular Normal . Chest Faint scattered wheezes bilaterally . Abdomen Benign . Extremities Warm with good distal pulses . There is no edema . Neurologic Able to follow simple commands . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "GENERAL He is a drowsy elderly white male lying with O2 on asking to be scratched . Blood pressure 110 50 pulse rate 94 respiratory rate 22 temperature maximum 101 degrees decreasing to",
"role": "user"
},
{
"content": " 99 degrees . SKIN Without rash or petechiae . HEENT Dry mucous membranes . NECK Supple . LUNGS Bibasilar crackles right greater than left no wheezes . CARDIAC Regular rate and rhythm S1 S2 I VI systolic ejection murmur . ABDOMEN Distended positive bowel sounds soft mild tenderness in the left lower quadrant no rebound . RECTAL Tender external hemorrhoids guaiac negative . EXTREMITIES Without edema . NEUROLOGIC Alert and oriented to person and place no asterixis or tremor . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Aortic stenosis . Coronary artery disease . Type I diabetes mellitus",
"role": "user"
},
{
"content": " . Peripheral vascular disease . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Seldane causes gastrointestinal",
"role": "user"
},
{
"content": " distress . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "In general confused white man in mild distress . Vital signs Temperature was 102 heart rate was 110 respiratory rate was 22 blood pressure was 113 63 . His head eyes ears nose throat was benign . His neck was supple . Lungs Rales at the",
"role": "user"
},
{
"content": " right base bilateral decreased breath sounds at the bases . Cor Regular rate and rhythm S1 and S2 no extra heart sounds abdomen distended with an epigastric mass noted mildly tender to palpation no guarding . Bowel sounds were present . The neurological examination was nonfocal . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Oxycontin Percocet Paxil Gabapentin Atenolol Discharge Disposition Extended Care Discharge Diagnosis benzodiazipine overdose Discharge Condition stable Discharge Instructions please take your medications and call your doctor if you experience chest pain abdominal pain or shortness of breath or any thoughts of hurting yourself or anyone else . Followup Instructions please call your primary doctor Edmund Starke",
"role": "user"
},
{
"content": " once your are discharge from the hospital Clemmie Shawn MD 65-948 Completed by Michael Melvin Kinzer MD 51-991 2012-03-26 1709 Signed electronically by DR. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is a 70-year-old female with cryptogenic cirrhosis . She has a history of esophageal varices and a history of an Upper GI bleed . She has had one pervious episode of variceal bleeding with an unclear date . However she is followed by a Dr. Joasscchird at Vaila Medical Center . She was in her usual state of health until one day prior to admission when she felt increasing fatigue nausea and vomiting productive of bright red blood and coffee ground emesis . She also had some black tarry stool in her colostomy bag . At Vaila Medical Center she had a hematocrit of 25 and was transfused 2 units of packed red blood cells . She had an upper endoscopy at Va Sit Namar Healthcare showing an esophagus filled with clots and small amount of bleeding varices clot in the stomach with antral gastritis and a normal duodenum . She was started on Pitressin a Blakemore tube was inserted . She was transferred to the Ph University Of Medical Center Intensive Care Unit where on January 25 in the morning her hematocrit was found to be 27.4 . She was transfused another 2 units of packed red blood cells over the course of the day and her hematocrit improved to 29.4 and then 31.2 . The GI service was consulted and an upper endoscopy study showed grade III varices with no active bleeding and a clean base gastric ulcer possibly secondary to the Blakemore tube . Her varices had stigmata of recent bleeding were banded successfully . after the procedure and 2 more units of packed red blood cells the patient was hemodynamically stable and hematocrit was stable at 31.2 . At that time she was transferred from the Intensive Care Unit to Coden 2 for the Lemgarson Hospital service . PAST MEDICAL HISTORY Cryptogenic cirrhosis with an unclear work up . Diverticular bleed requiring colostomy on May 96 . Spinal",
"role": "user"
},
{
"content": " stenosis . Hysterectomy at the age of 32 . No coronary disease no diabetes and no hypertension . She had medications on transfer which included Synthroid 0.15 mg QD Zoloft 50 mg QD Inderal 10 mg BID Prilosec 20 mg QD Neomycin 500 TID Feosol 3 mg and Darvocet PRN . She has allergies to Morphine Percocet Codeine Penicillin Xanax and Toradol . SOCIAL HISTORY She does not smoke tobacco . She uses only occasional alcohol and she is not sexually active . Her husband died of lung cancer . She lives alone in Burg Chi Sternafre Massachusetts . Her friends check up on her . She does not have a home health aide . She has 3 kids who live far away . She is able at baseline to walk one flight of stairs 2 floor apartment . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Remarkable for a white cell count of 0.4 with 0 neutrophils 0 bands 19 lymphs 0 monos hematocrit 28.8 platelets 300 000 . ALT 141 AST 40 alk phos 108 and a total bili of 1.0. Total protein was 5.7 albumin 2.5 and globulin 3.2 . His electrolyte panel of sodium 135 sodium 4.1 chloride 99 bicarb 30 BUN 15 creatinine 2.1 blood glucose of 196 . Iron studies included a ferritin of 607 an iron of 10 and a TIBC of 239 . EKG showed tachycardia with a sinus rhythm of 103 normal axis normal intervals no Q-waves no ST-T wave changes . The patient had a history from 7 12 01 of a normal white blood cell count with a normal absolute neutrophil",
"role": "user"
},
{
"content": " count . The patient &aposs chest x-ray at the outside hospital was unremarkable . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "A cachectic white female . T 100.1 P 104 blood pressure 130 90 heart rate",
"role": "user"
},
{
"content": " of 16 she was sating 95 on room air . HEENT Pupils were miotic measuring 2 mm but responsive to light . Neck Tender on the leftside with no lymphadenopathy or thyromegaly . Lungs were clear . Chest actually had a 5 x 7 cm necrotic area on the left chest wall with some pus . Cardiovascular Normal . Abdomen Normal . There was no HSM . Extremities Her left arm was very swollen . It was tested with no voluntary movement except at the finger tips . There was no edema elsewhere in her extremities only the left arm . Neuro The patient was oriented to place but had difficulty with recent memory . She also had mild weakness in the left extremities both upper and lower . Cranial nerves II XII were grossly intact . Toes were downgoing . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "His meds on",
"role": "user"
},
{
"content": " transfer to FIH were Levophed Dopamine and Ceftriaxone . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "On admission includes an electrocardiogram that shows DDD pacing . Hematocrit 39 percent white blood cell count 4500 PT and PTT normal . Sodium 140 potassium 4.2 chloride 105 carbon dioxide 30 BUN 24 creatinine 1.0 . HOSPITAL COURSE AND TREATMENT The patient was admitted to the Cardiac Catheterization Laboratory . There her pulmonary wedge pressure was 12 and her right atrial pressure was 4 and pulmonary artery pressure 44 17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted",
"role": "user"
},
{
"content": " for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20 under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm. which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase KS . ACHASTHA N. GRAFT M.D. TR hfr DD 08 22 1998 TD 08 27 1998 356 P cc ACHASTHA NICEMAEN GRAFT M.D. GITTETUMN DARNNAMAN <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Oxycontin Percocet Paxil Gabapentin Atenolol Discharge Disposition Extended Care Discharge Diagnosis benzodiazipine overdose Discharge Condition stable Discharge Instructions please take your medications and call your doctor if you experience chest pain abdominal pain or shortness of breath or any thoughts of hurting yourself or anyone else . Followup Instructions please call your primary doctor Edmund Starke",
"role": "user"
},
{
"content": " once your are discharge from the hospital Clemmie Shawn MD 65-948 Completed by Michael Melvin Kinzer MD 51-991 2012-03-26 1709 Signed electronically by DR. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Diabeta 10 mg. po. bid . Serax 20 mg. po. qhs . Sudafed 30 mg. po. bid . Theo-dur 300 mg. po. bid . Betoptic 0.5 one drop OU bid Propene 0.1 one drop OU bid Pred-Forte 1 one drop OS bid Percocet two tabs. po. q4hours prn . Proventil 2 puffs q6hours prn . PAST SURGICAL HISTORY includes and abdominoperineal resection in 1989 . ALLERGIES no known drug allergies PHYSICAL EXAMINATION demonstrated an obese man in no acute distress . The blood pressure 140 75 pulse 90 and irregular respirations 20 . The head eyes ears nose throat and neck examinations were unremarkable . Cardiac examination was remarkable",
"role": "user"
},
{
"content": " for frequent ectopic beats . The lung examination was clear but breath sounds were more pronounced on the left than the right . Abdomen soft obese with mild epigastric and right upper quadrant tenderness . An intact colostomy was present . No masses could be palpated secondary to the patient &aposs extreme obesity . Extremities unremarkable . The neurological examination was remarkable for a peripheral neuropathy including decreased sensation in the lower extremities with decreased strength in the upper and lower extremities most pronounced in the legs and feet . A chest X-ray demonstrated right hemidiaphragmatic elevation . The electrocardiogram was remarkable for trigeminy at 91 per minute . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Preoperatively the patient underwent chemo-embolization for his hepatocellular carcinoma . The remainder of his preoperative course was benign . On July 15 1992 a liver became available and the patient underwent hepatectomy and orthotopic liver transplant . His operation was complicated by severe coagulopathy requiring fifty-nine units of packed red blood cells 64 units of FFP and 34 units of platelets . Postoperatively the patient continued to have a coagulopathy requiring re-exploration on postoperatively day 2 with findings only of hematoma and no active bleeding . Initially the patient did well in the Intensive Care Unit mentally alert and oriented however he continued to be coagulopathic and was requiring large amounts of blood and FFP transfusions with a resultant pulmonary edema . He developed renal failure felt to be ATN secondary to ischemia of his kidneys . The patient remained intubated in the Intensive Care Unit for twelve days prior to his death . He had daily transfusions of FFP and blood and continued coagulopathy . He also developed thrombocytopenia requiring persistent platelet transfusions",
"role": "user"
},
{
"content": " on a daily basis . His immunosuppression was OKT3 and Solu Medrol and he underwent hemodialysis and ultra filtration to remove fluid . While in the ICU he developed seizures requiring large amounts of intravenous Valium to break his seizures and he was maintained on Tegretol and Dilantin . However he became progressively more mentally obtunded . During the seizure he bit his tongue resulting in a large bleed from his tongue which was sutured by the ENT Service however his continued coagulopathy resulted in bleeding from his nasopharynx which could never be identified and also upper gastrointestinal bleeding . Endoscopy never revealed specific sources of bleeding although he appeared to have a diffuse duodenitis . He was started on Pitressin to try to control the gastrointestinal bleeding but he continued to have severe bleeding and became progressively hypotensive with eventual bradycardia and cardiac arrest . He was pronounced dead at 349 PM on July 15 1992 . STA TITCHEGRIESESC M.D. DICTATING FOR KIVERL NA CANTSLEDDJESC M.D. TR wj bmot DD 07 28 92 <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "As above . PAST SURGICAL HISTORY As above MEDICATIONS ON ADMISSION Percocet and Naprosyn .",
"role": "user"
},
{
"content": " ALLERGIES Demerol <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted to the surgical intensive care unit where a continued cerebral angiogram was done that was essentially normal without evidence of any obvious aneurysm . The patient was observed for two days with a repeat CT scan showing no",
"role": "user"
},
{
"content": " changes from the previous examination . The headache stabilized after the patient was transferred to the floor . The patient continued to do well and the decision was made to discharge him . DISCHARGE INSTRUCTIONS The patient was discharged with strict instructions to return to the emergency room should there be an exacerbation of symptoms . CONDITION ON DISCHARGE Stable . DISCHARGE DIAGNOSES Ruled out subarachnoid hemorrhage . Michael Lawrence M.D. 41 -707 Dictated By Lena D. Mannie M.D. MEDQUIST36 D 2014-08-09 1404 T 2014-08-09 1527 JOB 45402 Signed electronically by DR. Michael Jackson on FRI 2014-09-05 1139 AM <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Topical Bactroban to be applied three times a day to affected naris prednisone 5 mg p.o. q.a.m. K-Dur 10 mEq x2 p.o. q.d. OxyContin 10 mg p.o. q.12h clindamycin 300 mg p.o. q.i.d. lisinopril 10 mg p.o. q.d. atenolol 25 mg p.o. q.d. trazodone 100 mg p.o. q.h.s. Prilosec 40 mg p.o. q.d clotrimazole 1 cream topical to be applied b.i.d. DISCHARGE FOLLOW-UP The patient was arranged for follow-up appointment with Dr. Scarvzine of rheumatology on 10 11 01 . Also with Dr. Fyfe of ENT scheduled for Halloween . Dr. Twada his primary care physician at the SBH clinic for 10 11 01 and Dr. Fyfechird gastroenterologist on 10 13 01 . COMPLICATIONS There were no complications during the patient &aposs hospitalization and he was discharged in stable condition . Dictated By THRYNE ANA",
"role": "user"
},
{
"content": " M.D. GN628 Attending DRIS UPHKOTE M.D. IF67 TB150 196806 Batch 48373 Index No. RYZKWV6XG4 D <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Atrial fibrillation secondary to hyperthyroidism initially diagnosed in 2005 Status post current cardioversion times four Hyperthyroidism status post radioactive iodine ablation . Status post carpal tunnel release Status post umbilical hernia repair . Hypertension MEDICATIONS",
"role": "user"
},
{
"content": " AT HOME 1. Accupril 40 mg q.d. Aspirin 325 mg q.d Clonidine 0.1 mg b.i.d. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Ms. Less is a 79 year old white female with history of non small cell lung cancer diagnosed in 02 95 . She underwent a resection for",
"role": "user"
},
{
"content": " stage I in 10 95 and treated with XRT . She presented to the hospital with a numb right leg this morning and underwent an emergent embolectomy . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Chem-7 Na 139 K 3.7 Cl 99 bicarb 28 BUN 15 creatinine 0.9 glucose 89 . Liver",
"role": "user"
},
{
"content": " function tests were significant for an ALT 41 AST 31 alk phos 76 T. bili 0.7 D. bili 0.2 amylase 345 lipase 2510 T. protein 8.1 albumin 4.9 globulin 3.2 Ca 9.9 . CBC White blood cell count 8.82 hemoglobin 15.2 hematocrit 43 and platelets 322 . Imaging studies Abdominal CT scan on 2 21 00 Study revealed a prominent pancreas with associated mesenteric stranding . No abscess or pseudocyst . A small gallstone was noted in the gallbladder neck . Bilateral pleural effusion were seen with associated compression atelectasis . Abdominal ultrasound on 2 23 00 This study revealed gallbladder sludge but no cholelithiasis . There was swelling of the body and tail of the pancreas . Portable chest on 2 23 00 Lungs were clear . Heart was normal . There was no pleural effusion . Chest PA and lateral on 2 25 00 Lungs were clear . There was no infiltrates or consolidation . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Morphine prn . Ativan prn . Tylenol prn . Albuterol and Atrovent nebs prn . Rice S.F. Thrash M.D. 15-419 Dictated By Brett",
"role": "user"
},
{
"content": " E.X. Im M.D. MEDQUIST36 D 2012-06-29 0115 T 2012-06-29 0547 JOB 44693 Signed electronically by DR. Vicki Baker on TUE 2012-07-03 823 AM <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted with a right occipital cerebral infarction . The patient was started on intravenous heparin and had the studies as described above for rule out source of embolic strokes including carotid noninvasives transcranial Dopplers Holter electrocardiogram and echocardiogram . The patient also had serial electrocardiogram which showed no change . The patient also had serial creatinine kinase with MB fractions studied which revealed MB fraction too low to be tested . The patient also experienced a feeling of moving back and forth when lying down with neck extended during the magnetic resonance imaging study and also in bed . This moving sense with normal electroencephalogram was thought to be a mild vestibular dysfunction or from the acute episode of the stroke . The patient will have these symptoms only when the eyes are closed . Our opinion was not to intervene or have any further studies for acute period and to continued to observe . The patient did have a hypotensive episode and the systolic blood pressure was 80 after the patient received his regular cardiac medications . The patient had been off his regular medications since during the admission and will be discharged off his medications . Otherwise there were no further episodes of blurred vision . The patient was stable with an unchanged neurological and physical examination and was discharged on aspirin 325 mg po qd on May 14 1995 . The patient will be randomized on the Wars study early next week by the Stroke Service at Ph University Of Medical Center . CONDITION ON DISCHARGE The patient was stable with the physical examination as described above . DISCHARGE ORDERS Medications aspirin 325 mg po qd Glipizide 25 mg po qd . The patient will be discharged home without his regular cardiac medications . The patient will be followed by Dr. Ketyvi Liftjesc of the Neurology Service at Ph University Of Medical Center on May 17 1995 for randomization on the Wars study . The patient will be also followed by Dr. Joseet Gelineau of the Neurology Service at Ph University Of Medical Center . The patient will also be followed by Dr. Margmimaui Gelineau his primary care physician at Ochtuheihugh Put University Medical Center within one week after discharge",
"role": "user"
},
{
"content": " . The patient will also be followed by his regular Urologist at Ochtuheihugh Put University Medical Center within one week after discharge for his continuing hematuria . JOSEET GELINEAU M.D. TR lj bmot DD 05 13 95 TD 05 17 95 CC <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted to the Intensive Care Unit . He was also seen by the Orthopedics Service and Neurosurgical Service . He went to the Operating Room quickly and had an intramedullary rodding of the femur and open reduction and internal fixation of the radius and ulna . He was evaluated by Neurosurgery for his head injury which showed multiple contusions in the frontal lobe . He was extubated on postoperative day two . He did have some blood loss anemia with a hematocrit of 20.9 . A repeat CT scan showed no change . He was begun on Physical Therapy but remained agitated . He was discharged to the Floor . His hematocrit remained stable . His cervical spine was cleared . The patient was seen by Psychiatry due to some delirium and question of suicidal ideation . He was also evaluated by the Neuro-Rehabilitation Service who thought that",
"role": "user"
},
{
"content": " he had a post-head injury syndrome with diffuse cognitive deficits . He continued to have some episodes of agitation which were treated with medication . He required some sedation and restraint and was begun on whatever Physical Therapy he could have given his head injury . He was continued to be followed by Psychiatry and then was casted by Orthopedics . He continued to have episodes of confusion . He removed the cast that had been placed and then a long-leg cast was then placed so it would be difficult for him to remove or to ambulate on his leg which might jeopardize his closure . It continued to be somewhat difficult to control his activity and Rehabilitation Screen was in place but there was difficulty finding the appropriate facility . His family was also involved in his care and orientation . He does of BuSpar Trazodone and Haldol were continued and were adjusted by Psychiatry . He was continued on observation and sitters and finally became more docile and cooperative . He was continued on Physical Therapy and with his mother present he began to follow commands much more appropriately and was able to be rehabilitated . He was finally sent home for home rehabilitation on 2011-02-23 . FINAL DIAGNOSES Multiple trauma with severe frontal head injury . Open fracture of the femur . Radial and ulnar fractures . Liver laceration . SURGICAL PROCEDURES Open reduction and internal fixation of femur 2011-01-21 . Open reduction and internal fixation of radius and ulna 2011-01-21 . DISCHARGE MEDICATIONS 1. Percocet one p.o. q. four hours p.r.n. pain . 2. Haldol 1 mg p.o. q. four to six hours p.r.n. agitation . Trazodone 50 mg p.o. q. h.s. Droperidol 1.5 to 2.5 mg p.r.n. agitation . DISPOSITION The patient is discharged home with home rehabilitation . DISCHARGE INSTRUCTIONS The patient will be followed by Orthopedics Dr. Johnson . To be followed by William Scheidel of Neurological Rehabilitation . Maria L. Bell M.D. 05-084 Dictated By Michael X. Fisher M.D. MEDQUIST36 D 2011-04-08 1401 T 2011-04-10 0809 JOB 48774 Signed electronically by DR. Fredrick Rossi on WED 2011-04-13 <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "On physical exam she was noted to have bilateral lower extremity edema mildly elevated pressures in the 140 to 150 90 range and jugular",
"role": "user"
},
{
"content": " venous distension . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "She was admitted to the ICU for close neurosurgical and neurological observation . She remained neurologically stable . Repeat head CT showed stable bleed . The patient was transferred to the regular floor . She was out of bed ambulating tolerating a regular diet voiding spontaneously . She will be discharged to home with followup with Dr. Wilson in two weeks with a repeat head CT . MEDICATIONS ON DISCHARGE 1. Levofloxacin 250 mg p.o. q.24h. x3 days . 2. Dilantin 100 mg p.o. t.i.d. Colace 100 mg p.o. b.i.d. Timoptic 0.25 one drop O.U. b.i.d. 5 . Lantoprost 0.005 ophthalmic solution one drop O.U. q.h.s. Zantac 150 mg p.o. b.i.d. Insulin-sliding scale as well as 40 units of Humalog in the a.m. and 20 at night . CONDITION ON DISCHARGE Stable . FOLLOW-UP INSTRUCTIONS She will follow up with Dr. Perez in two weeks with repeat head CT . Danvers T Sharp M.D. 16 -530 Dictated By David GA Crane M.D.",
"role": "user"
},
{
"content": " MEDQUIST36 D 2012-04-30 1130 T 2012 -05-01 0813 JOB 10027 Signed electronically by DR. Margarita Martin on TUE 2012-06-05 <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Albuterol inhaler . Amphotericin B 40 mg. qday . Ceftazidime 1 gram intravenous q 8 . Ciprofloxacin 500 mg. po. q12 . Cisapride 10 mg. po. qid . Dakin &aposs solution 1 4 strength to ulcer of penis . Benadryl 50 mg. intravenous tid prn . capsule 1 po. tid . Lasix prn",
"role": "user"
},
{
"content": " . Nystatin swish and swallow tid . Percocet po. q4 to 6 prn . Trazodone 50 mg. qhs. multivitamins 1 po. qd . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "No family history of heart disease or cancer Physical Exam PE Tc 98.7 pc 88 bpc 120 60 AC 600 20 FiO2 100 PEEP 10 Gen young male intubated sedated in hard collar . HEENT Pupils pinpoint equal anicteric normal conjunctiva intubated OGT in place OMMM normocephalic atraumatic Cardiac RRR I VI SM at apex no R G appreciated Pulm coarse breath sounds throughout Abd mildly distended hypoactive BS soft no HSM Ext trace LE edema at ankles extremities cool w 2 radial 1 DP PT pulses . Well-healed scars over dorsal lateral distal LUE Neuro DTR 3 upper and lower extremities symmetric bilaterally . Toes equivocal bilaterally . gag Pertinent Results EKG NSR 92 bpm nl axis borderline QT QTc 0.442 J Pt elevtation V3 TWF II III avF I avL no prior EKG for comparison 2012-03-23 0339 PM TYPE ART PO2 122 PCO2 38 PH 7.43 TOTAL CO2 26 BASE XS 1 2012-03-23 0339 PM LACTATE 2.0 2012-03 -23 0130 PM URINE HOURS RANDOM 2012-03 -23 0130 PM URINE bnzodzpn POS barbitrt NEG opiates NEG cocaine NEG amphetmn NEG mthdone NEG 2012-03 -23 0130 PM URINE COLOR Straw APPEAR Clear SP Barajas 1.015 2012-03-23 0130 PM URINE BLOOD SM NITRITE NEG PROTEIN 30 GLUCOSE 1000 KETONE NEG BILIRUBIN NEG UROBILNGN NEG PH 6.0 LEUK NEG 2012-03 -23 0130 PM URINE RBC 03 -10 WBC 0-2 BACTERIA FEW YEAST NONE EPI 0 2012-03 -23 0130 PM URINE MUCOUS FEW 2012-03-23 1222 PM PO2 44 PCO2 82 PH 7.14 TOTAL CO2 30 BASE XS - 4 2012-03-23 1222 PM GLUCOSE 296 LACTATE 4.8 NA 140 K 5.2 CL - 101 2012-03-23 1220 PM UREA N 20 CREAT 1.1 2012-03-23 1220 PM ALTSGPT 30 ASTSGOT 38 LDLDH 217 CKCPK 1152 ALK PHOS 52 AMYLASE 426 TOT BILI 0.4 2012-03-23 1220 PM LIPASE 22 2012-03-23 1220 PM CK-MB 45 MB INDX 3.9 cTropnT 0.01 2012-03-23 1220 PM ALBUMIN 4.4 2012-03-23 1220 PM ASA NEG ETHANOL NEG ACETMNPHN NEG bnzodzpn NEG barbitrt NEG tricyclic NEG 2012-03-23 1220 PM WBC 8.9 RBC 3.93 HGB 12.1 HCT 36.7 MCV 93 MCH 30.8 MCHC 33.0 RDW 13.0 2012-03-23 1220 PM NEUTS 84.7 LYMPHS 13.1 MONOS 1.5 EOS 0.3 BASOS 0.4 2012-03-23 1220 PM PLT COUNT 227 2012-03-23 1220 PM PT 14.1 PTT 21.0 INRPT 1.2 2012-03-23 1220 PM FIBRINOGE 375 2012-03-26 0430 AM BLOOD WBC 6.9 RBC 3.28 Hgb 9.8 Hct 29.0 MCV 89 MCH 29.7 MCHC 33.6 RDW 13.1 Plt Ct 206 2012-03-26 0430 AM BLOOD Plt Ct 206 2012-03-26 0430 AM BLOOD Glucose 88 UreaN 10 Creat 0.7 Na 143 K-3.6 Cl 108 HCO3 28 AnGap 11 2012-03-26 0430 AM BLOOD Calcium 8.5 Phos",
"role": "user"
},
{
"content": " 3.1 Mg 1.9 2012-03-25 0400 AM BLOOD calTIBC 237 Ferritn 534 TRF 182 Brief Hospital Course A 39 year old male w HTN chronic LBP on narcotics presents after being found unresponsive at home . P 1 Unresponsiveness This is likely due todrug overdose known oxycontin use BNZ on tox screen . Ddx cardiac ischemia no ischemic EKG changes noted seizure w post-ictal state CVA head CT neg . His cardiac enzymes include only elevated CK but not Shaffer Juan he ruled out for MI . His mental status gradually improved from 03-23 to 03-24 . He was able to communicate appropriately as his level of narcotic medications waned in his blood . He was able to maintain a stable mental level for extubation on 03-24 . As of 3 21 he was alert appropriate and answers questions and follows command on exam . Pulmonary infiltrates THere was initially concern that he was developing ARDS from aspiration pneumonia in the setting of being found unconscious . He was intubated and was on mechanical ventilation from 9 13-10 11 but he was started on levofloxacin and flagyl for total of 4 days . ON 03-26 his antibiotics were started as this most likely represent a transiet aspiration episode and not ARDS . Airway protection He was intubated in the field for airway protection He was extubated on 03-24 and was weaned off oxygen slowly from 03-24 to 03-26 without significant event . Hypertension He was restarted on his atenolol and verapamil once his blood pressure stabilized on 03-25 . 5 Depression He was restarted on his paxil on 03-25 and was given 11 sitter for suicidal ideation leading up to his suicide leading up to this admission . He has not had further episodes while he was in the hospital . plan to restart Paxil when taking PO 6 Hyperglycemia Although he has no known history of diabetes his elevated FS noted in field with glycosuria prompted fingerstick check but he has not required insulin coverage . 7 High amylase He was admitted on 03-23 with elevated amylase but non-elevated lipase . This likely is not concerning of pancreatic process . His amylase trended down . He was restarted on regular diet on 4 14-4 17 after his extubation 8 Anemia He was admitted with borderline anemia with Fe studies suggestive of anemia of chronic disease and his hct decreased in the setting fluid resucitation . His hct has stabilized and improved to close to 30 at the time of 3 21 . He reports that his primary physician is aware of his anemia and was in the process of followup . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "White blood cell count was 8.5 80 percent neutrophils 13 percent lymphocytes hematocrit 27.4 platelet count 277 000 . Sodium 133 potassium 4.8 chloride 94 bicarbonate 24 blood urea nitrogen 39 creatinine 2.0 glucose 111 . CK 152 CK MB 3.0 troponin 0.04. INR 1.1. Chest",
"role": "user"
},
{
"content": " x-ray showed equivocal retrocardiac opacity . Electrocardiogram showed sinus bradycardia at 40 beats per minute . First degree AV block with PR interval 220 left axis deviation right bundle branch block with a left anterior fascicular block 0.1103 N. Fifth Cir. depressions in V4 through V6 . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Discharge medications Baclofen 10 p.o.",
"role": "user"
},
{
"content": " t.i.d. MVI one tablet p.o. q.d. Mycostatin powder TP q.d. to be applied to the rash in her left groin area also dilaudid 8 mg p.o. q2h Colace 100 mg p.o. b.i.d.', 'coumadin 2.5 mg p.o. q.h.s. fentanyl patch 75 micrograms per hour topical q72 hours atenolol 100 mg p.o. q.d. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Aspirin under which she develops worsening of her shortness of breath and asthma flare tetracycline sulfa Demerol . MEDICATIONS Diovan 106 mg q.d. Advair 500 50 two puffs b.i.d. Plavix 75 mg q.d. Crestor 20 mg q.d. Neurontin 300 mg t.i.d. Prilosec 20 mg b.i.d. Vicodin as needed . Trazodone 50 mg q.d. Singulair 10 mg q.d. Flexeril 10 mg t.i.d. 11. Lopressor 75 mg b.i.d. Humibid 3600 b.i.d. Colace 100 mg b.i.d. Zetia 10 mg q.d. Benadryl as needed . Tricor 106 mg q.d. Premarin 0.3 mg q.d. Prozac 40 mg q.d. 19. Omega-3 fatty acids t.i.d. 1. Chest pain The patient ruled out for myocardial infarction . However with her history of disease patient underwent a cardiac catheterization .', 'The patient was found at cardiac catheterization to have mild diffuse instent restenosis in the mid stent otherwise hemodynamically normal and the coronary arteries', 'otherwise were without flow-limiting stenoses .",
"role": "user"
},
{
"content": " The patient was then continued on her cardiac medications . It was felt that if we attempted aspirin desensitize her while an inpatient', 'then she would benefit from the use of aspirin and Plavix . The patient was sent to the CCU and underwent aspirin desensitization protocol which she tolerated well .', 'She had mild worsening of her asthma attacks which was relieved by Benadryl and occasionally albuterol . The patient found that if she took the aspirin in the evening with her Benadryl', 'that she takes for sleep that the asthma exacerbation did not occur . Aspirin no longer should be considered an allergy for this patient and she is going to take this as an outpatient .', '2. Hyperlipidemia The patient s Lipitor was increased to 80 mg q.d. 3. Back pain This is a chronic issue and was controlled with Flexeril and Vicodin . DISPOSITION To home . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "On physical examination blood pressure is 130 80 pulse 74 and regular respirations 14 . Her chest demonstrated bibasilar crackles . Cardiovascular exam the jugular venous pressure was seven centimeters carotid upstroke normal . The heart exam revealed a normal Sl and S2 was normally split . There was an S4 no S3 grade II VI apical murmur in systole no rubs . The abdomen was benign unremarkable . Extremities no calf tenderness or peripheral edema",
"role": "user"
},
{
"content": " . Peripheral pulses were 2 and symmetrical bilaterally . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "No known drug allergies . MEDICATIONS ON ADMISSION 1. Evista 60 mg p.o. daily . 2. Tamoxifen 20 mg p.o. daily . 3. Lisinopril 5 mg p.o. daily . 4. Triamterene Hydrochlorothiazide 37.5 25",
"role": "user"
},
{
"content": " mg p.o. daily . 5. Enteric Coated Aspirin 325 mg p.o. daily . 6. Meclizine 25 mg q8hours p.r.n. Aggrenox twice a day the dose was not known . Synthroid 125 mcg daily . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Prednisone 60 mg daily for 4 days . Continue inhalers as prescribed . Disposition Follow up and Instructions to Patient",
"role": "user"
},
{
"content": " Call Dr. Linketerf tomorrow and make an appointment for follow-up on the lung nodule . THIS IS VERY IMPORTANT . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Significant for an appendectomy in the distant past cholecystectomy in the past history of of Cesarean section in the past and a history of near total thyroidectomy for nodular goiter in the past MEDICATIONS ON ADMISSION Her only medication is Thyrolar for her relative hypothyroidism following resection There is a question of an allergy to Tylenol . She denies any history of hypertension diabetes mellitus coronary",
"role": "user"
},
{
"content": " artery disease or peptic ulcer disease Interestingly she reports that both her mother and father died of stomach carcinoma . She is a former smoker and drinks alcohol occasionally <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Coumadin 2.5 mg.",
"role": "user"
},
{
"content": " five times a week Ativan and Lomotil prn . ADVERSE DRUG REACTIONS no known drug allergies but has shellfish allergy and question of an Iodine allergy . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Right",
"role": "user"
},
{
"content": " sided chest pain by several hours . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted on 9 14 93 and underwent on that same day a left axillary lymph nodes dissection by Dr. Ausguall . The patient tolerated the procedure well there were no complications . Postoperative course was unremarkable . The",
"role": "user"
},
{
"content": " patient was discharged home on 9 15 93 . At that time her JP was still in place . DISPOSITION Patient will follow up with Dr. Ausguall in about 4-5 days at which time the JP drain will be removed . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "A Neurosurgery consultation was obtained and it was their impression that the patient &aposs paraplegia might possibly represent a cord concussion and recommended treatment with intravenous steroids for 24 hours . The patient &aposs paraplegia resolved by the morning of her second hospital day and she maintained 5 5 motor strength in all groups . A Urology consultation was obtained and it was recommended that an IVP be obtained . This was obtained on the day of discharge however due to residual contrast in the colon from the patient &aposs prior abdominal CT scan the exam was postponed after a scout film was obtained . The",
"role": "user"
},
{
"content": " patient fell well on the day of discharge . She remained afebrile throughout her hospital course . Additionally on the night before discharge flexion and extension views of the lumbosacral spine were obtained and showed no fracture or instability . DISPOSITION CONDITION ON DISCHARGE Good . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Ms. Less is a 79 year old white female with history of non small cell lung cancer diagnosed in 02 95 . She underwent a resection for stage I in 10 95 and treated with XRT . She presented to the hospital with a numb right leg this morning",
"role": "user"
},
{
"content": " and underwent an emergent embolectomy . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Coronary",
"role": "user"
},
{
"content": " artery disease status post coronary artery bypass grafting times three . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted on 9 14 93 and underwent on that same day a left axillary lymph nodes dissection by Dr. Ausguall . The patient tolerated the procedure well there were no complications . Postoperative course was unremarkable . The patient was discharged home on 9 15 93 . At that time her JP was still in place . DISPOSITION Patient will follow up with Dr. Ausguall in about 4-5 days at",
"role": "user"
},
{
"content": " which time the JP drain will be removed . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Lisinopril 5 mg p.o. q. day . Metoprolol 37.5 mg p.o. twice a day . 3. Lipitor 10 mg p.o. q. day . Pantoprazole 40 mg p.o.",
"role": "user"
},
{
"content": " q. day . Levothyroxine 100 micrograms p.o. q. day . DISCHARGE INSTRUCTIONS The patient was to arrange his follow-up with his primary care physician Bryan Smith . To follow-up with his Cardiologist Dr. Delores Padilla within one to two weeks of discharge . Tammy Thompson M.D. 40-318 Dictated By Randolph Q Barber M.D. MEDQUIST36 D 2015-11-26 1515 T 2015-11-26 1610 JOB 90402 Signed electronically by DR. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "ON ADMISSION This is a gentleman who is intubated comfortable with minimal sedation . He was afebrile with a temperature of 99.1 . His pulse was in the 70s blood pressure 119 58 . He was breathing 12 per minute and saturating 98 . His CVP is ranging from 07-27 . He was intubated and has a nasogastric tube . His neck has a well-healed right carotid endarterectomy scar . There is also a well-healing tracheostomy scar . The lungs were clear to auscultation bilaterally . The heart was regular with an S1 and S2 . The abdomen was soft nontender nondistended with normoactive bowel sounds . The",
"role": "user"
},
{
"content": " extremities were without edema . The left arm was in a cast . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was brought to the Operating Room on April 22 . She underwent a mitral valve replacement utilizing a 27 mm . St. Jude prosthesis and tricuspid valve reconstruction by ring anuloplasty . She weaned from cardiopulmonary bypass with good hemodynamics . She initially awoke after surgery with good hemodynamics . She was transiently in sinus rhythm but atrial fibrillation recurred . She was extubated on the third postoperative day and was initially slightly agitated and confused largely due to an Intensive Care Unit psychosis . She continued to improve with mobilization of fluid",
"role": "user"
},
{
"content": " . She was initially noted to have a slow ventricular response in atrial fibrillation but this gradually improved over time . She was initially noted to be somewhat anemic and received transfusions . Coumadin was restarted and her anticoagulation came into range . She was ultimately discharged with a heart rate in the 90 s and with resolving edema and a clear chest . Her MEDICATIONS ON DISCHARGE included Lasix 40 b.i.d. potassium 20 mEq b.i.d. iron and folic acid replacement and Coumadin . RIEMUND C. ALL M.D. TR dun bmot DD 7 12 94 TD <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Her allergies are penicillin",
"role": "user"
},
{
"content": " which cause throat edema . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Is as follows History of coronary artery disease with status post two-vessel CABG in 1986 also he was treated for congestive heart failure hypertension aortic valve replacement and mitral valve replacement with St. Jude &aposs valve in 09 2001 atrial fibrillation history of prior GI bleed",
"role": "user"
},
{
"content": " requiring blood transfusions during which he also had a colonoscopy on 05 2003 which demonstrated no neoplasia and scattered diverticuli . The patient also following his first GI bleed had an EEG done in 07 2003 which showed gastritis with oozing and evidence of a recent bleed <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Patient has allergies to penicillin . She gets hives . Bactrim she gets hives . Percocet and erythromycin she",
"role": "user"
},
{
"content": " gets gastrointestinal upset and Keflex she gets hives . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Levoxyl 112 mcg",
"role": "user"
},
{
"content": " q.d. Prozac . Codeine for cough . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "1 Bronchiolitis obliterans organizing pneumonia The video assisted thoracoscopic study at the outside hospital was consistent with bronchiolitis obliterans organizing pneumonia . The patient was continued on steroids throughout the course of her stay . This was changed to Solu-Medrol part way through the course due to her hematologic problems see below . By discharge she was returned to 40 mg of Prednisone q. day times one month to be followed by a slow taper . The patient &aposs bronchiolitis obliterans organizing pneumonia appeared to improve slowly throughout her hospital course however on July 12 1998 after starting dialysis see below the patient desaturated and required supplemental oxygen . Repeat chest x-rays and chest CT scans appeared consistent with pulmonary edema from volume overload given her renal failure and eventually the patient &aposs pulmonary status did improve after significant volume removal with dialysis for several weeks . At the time of her discharge the patient was still requiring two liters of supplemental oxygen to maintain her oxygen saturations in the mid 90 . 2 Thrombotic thrombocytopenic purpura The patient was initially admitted with platelet count of 28 hematocrit of 32 LDH of 496 with 2 schistocytes and 2 spherocytes on her smear . This was felt to be consistent with thrombotic thrombocytopenic purpura and on June 20 1998 she was started on daily plasma exchange which continued through July 27 1999 . She was also changed to intravenous Solu-Medrol 50 mg q. day which was changed back to 40 mg of Prednisone prior to discharge . Her platelet count initially rose to a maximum of 159 on July 3 1998 then they steadily fell to a low of 60 on July 20 1999 . Her LDH which peaked at 1255 decreased to the mid 200s but remained elevated . She continued to have a few schistocytes on her smear but it was much decreased . The patient also required red blood cell transfusions approximately two units every seven to ten days to maintain her hematocrit . Eventually her plasma exchange was tapered to a smaller and smaller dose each day and then discontinued altogether after July 27 1999 . After this the patient &aposs platelet count rose to a maximum of 177 on discharge . It is felt that the patient &aposs thrombotic thrombocytopenic purpura has resolved . She will continue on her Prednisone for one month as above for the bronchiolitis obliterans organizing pneumonia with a very slow taper . 3 Renal The patient presented in acute renal failure with a BUN of 101 and a creatinine of 3.7 . Throughout the month of June she had a rising Potassium phosphate and increasing volume overload with decreasing response to diuretics and she was finally initiated on dialysis with ultrafiltration on July 12 1998 . The opinion of the Renal consult was that this was permanent and non-reversible renal failure since it did not improve with dialysis and the patient will continue on dialysis three times per week . She required approximately five liters of ultrafiltration fluid removal at each dialysis session due to her significant volume overload . During the course of her dialysis she had a great improvement in her lower extremity edema and her oxygen saturation . 4 Infectious disease The patient had multiple line infections during her admission including a confirmed coag. negative Staphylococcus line infection with positive blood cultures on June 23 1998 July 4 1998 July 8 1998 and July 9 1998 . The patient eventually had a left subclavian Tesio catheter placed and a right brachial PICC line placed on July 10 1998 which remained patent and uninfected . She received a full three week course of Vancomycin and also received a three week course of Ceftazidime . In addition she had a fungal urinary tract infection treated with Amphojel bladder irrigation which was followed by a Klebsiella urinary tract infection for which she received Levofloxacin times fourteen days . She also received a fourteen day course of Acyclovir which was begun on June 21 1998 for perianal lesions consistent with herpes simplex virus . She was also on Fluconazole for some oral thrush which was inadvertently continued for a total of thirty days . The patient was also started on Bactrim one double strength tablet q.o.d. as prophylaxis for Pneumocystis carinii pneumonia while on her high dose steroids . 5 Rheumatology The patient was admitted with a question of lupus given her ANA of 1640 although her rheumatoid factor and ANCA were negative . Unfortunately throughout her admission we were unable to test any more titers since she was receiving daily plasma exchange . A repeat ANA rheumatoid factor and ANCA may be repeated as an outpatient . FOLLOW-UP 1 The patient will follow-up with her primary care physician Dr. Tamarg Study in Arvus after she is discharged from rehabilitation . 2 The patient is being discharged to A Hospital where she will receive onsite hemodialysis three times per week on Monday Wednesday and Friday . The nephrologist who will follow her there is Dr. Study . 3 The patient will continue to have her CBC LDH bilirubin chem-7 and magnesium and calcium checked with each dialysis and the results will be faxed to Dr. Ian Zineisfreierm the hematology attending at fax number 751-329-8840 . 4 The patient will eventually need a permanent dialysis fistula . The left subclavian Tesio which she has in place will last for several months in the mean time . She would like to arrange to have her fistula placed at Pre Health and the vascular surgeons there should be contacted regarding this . 5 The patient will need packed red blood cell transfusions with dialysis when her hematocrit falls below 26 . 6 The patient will continue her Prednisone at 40 mg p.o. q. day times one month this was started on July 27 1999 and then she will begin a slow taper as guided by Pulmonary . 7 The patient has a follow-up appointment in the Pulmonary Clinic with Dr. Cedwi Stone at 336-2931 on August 30 1999 at 140 PM . 8 The patient has a follow-up appointment with Dr. Ian Zineisfreierm at the We Erthunt Hospital at 180-0455 on August 15 1999 at 1230 PM . MEDICATIONS ON DISCHARGE 1 Calcitriol 0.25 mcg p.o. q. day . 2 TUMS 1250 mg p.o. t.i.d. 3 Premarin 0.625 mg p.o. q. day . 4 Colace 100 mg p.o. b.i.d. 5 Humulin sliding scale q.a.c. and q.h.s. 6 Labetalol 400 mg p.o. t.i.d. 7 Omeprazole 20 mg p.o. q. day . 8 Serax 15",
"role": "user"
},
{
"content": " mg p.o. q.h.s. p.r.n. insomnia . 9 Prednisone 40 mg p.o. q. day times thirty days beginning on July 27 1999 to be followed by a slow taper as directed by the pulmonologist . 10 Metamucil one packet p.o. q. day . 11 Amlodipine 10 mg p.o. q. day . 12 Bactrim Double Strength one tablet p.o. q.o.d. 13 Nephrocaps one tablet p.o. q. day . 14 Epogen 1 000 units subcutaneously three times per week . 15 Iron sulfate 300 mg p.o. t.i.d. Dictated By CHELA FYFENEIGH M.D. NY5 Attending LENNI E. NECESSARY M.D. BE1 IZ845 6789 Batch 7665 Index No. YQGKGG4LST D 08 01 98 T 08 01 98 CC CEDWI STONE MD BMH PULMONARY CLINIC TAMARG STUDY MD Port O <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "At the time of admission laboratories were remarkable for a partial thromboplastin time of 31.7 INR 1.4 potassium 3.2 glucose 182 lactate was initially 6.6 . Urine toxicology screen",
"role": "user"
},
{
"content": " was negative . Serum toxicology screen was positive for TCA s. Tylenol level was 15 . Alcohol level was 199 . Initial blood gas was 7.31 46 500 77 . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted to the Step Down Unit for a rule out MI protocol . He was treated with aspirin heparin and intravenous nitroglycerin . No beta blockers was started because of his history of hypertension with beta blockers and because his blood pressure of only 110 70 . The patient ruled in for myocardial infarction with a peak CPK of 219 and 20.9 MB fraction . This was a non-Q wave myocardial infarction as there were no diagnostic electrocardiogram changes . on 10-27-93 the patient went to the cath lab which revealed a small nondominant right coronary artery without any lesions a restenosis of the proximal left anterior descending lesion that had been PTCA &aposd a lesion in the first OM and a moderately severe left circumflex lesion after the OM3 . The left ventriculogram revealed an akinetic anterolateral and apical ventricle . Given the results of this cardiac catheterization which were not significantly changed from his previous cardiac catheterization prior to the PTCA it was elected to attempt to medically manage the patient . He was ambulated progressively on the floor . A beta blocker was started with Metoprolol initially at 25 mg PO bid and eventually increased to 50 mg PO bid . The patient ambulated extensively on the FIH 20 floor each day without any episodes of chest pain or shortness of breath . On 11-2-93 the patient underwent a low level treadmill exercise test with Thallium imaging . This treadmill test was done on medications including beta blockers in hopes to assess an amount of ischemia on treatment . The patient was able to exercise for approximately nine minutes on a modified Bruce protocol however he did not reach his predicted maximal heart rate while he was on the beta blockade . There were no diagnostic electrocardiogram",
"role": "user"
},
{
"content": " changes during the treadmill exercise test although he did have 0.5 to 1 mm ST depression in II III and AVF . The study was halted for shortness of breath and there was no chest pain . Thallium images revealed a moderate sized region of ischemic but viable myocardium involving the anteroseptal and lateral segments of the left ventricle . There was also some evidence of left ventricular dysfunction during the test . These images were essentially unchanged compared with the previous Thallium images in May 1993 . After extensive discussion between myself Dr. Amesin and Dr. Scgach it was elected to discharge the patient to home with medical management . The patient was extremely reluctant to undergo surgery although he understands that this may become necessary in the future . Dr. Amesin had a long discussion with the patient &aposs daughters revolving primarily around issues of the patient &aposs compliance . Previously he had not taken any of his medicines and smoked heavily on the outside and not kept any of his appointments . The importance of quitting smoking as well as continuing to follow his medical regimen was emphasized to the daughter and to the patient . She will be actively involved in encouraging the patient to comply with this medical regimen and also to follow up with Dr. Amesin as well as Dr. Lfsquarc on the outside . The patient remained guaiac negative throughout the entire hospitalization . Despite being on heparin for a short time his hematocrit remained very stable with only a small dip after the catheterization was done . He will need to be followed up as an out patient for guaiac positive stools and possibly worked up for this in the future . CAGHALA UINTEELE M.D. TR yf bmot DD 11-3-93 TD 11 04 93 CC <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Discharge medications include 1. Indomethacin 25 mg p.o. t.i.d. for seven days. Atenolol 50 mg p.o. q.d. Lipitor 10 mg p.o. q.d. Baby aspirin 81 mg p.o. q.d. Iron sulfate 81 mg p.o. q.d. Accupril 40 mg p.o. q.d. Hydrochlorothiazide 12.5 mg p.o. q.d. NPH insulin 18 units q.a.m. and 10 units q.p.m. 9. Humalog sliding-scale q.a.m. and q.p.m. DISCHARGE FOLLOWUP The patient was to follow up with his primary cardiologist Dr. Thomas within one week . David Archibald M.D. 11-989 Dictated By Dorothy Y. Madore M.D. MEDQUIST36 D 2009-11-12 1202 T 2009-11-12 1744 JOB 33199 cclist",
"role": "user"
},
{
"content": " Signed electronically by DR. Susan O. G. Aviles on Robert 2010-01-14 <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "BY SYSTEM Respiratory The baby was intubated in the Delivery Room received two doses of surfactant . Radiograph revealed bilateral diffuse granular pattern consistent with surfactant deficiency . Maximum mechanical ventilation PIP 26 PEEP 6 rate of 25 maximum FIO2 35 percent . Mychelia was extubated to a CPAP of 6 cm on day of life two where she remained until day of life 20 . On day of life two she was also loaded with caffeine and continues on caffeine at time of transfer . She was transitioned to a nasal cannula on day of life 20 and remains on nasal cannula O2 100 percent at 13 cc flow . She averaged 2-3 apnea episodes a day with bradycardia and desaturations . She has a comfortable respiratory rate and good air exchange . Cardiovascular She received a normal saline bolus times one initially for poor perfusion and was started on dopamine with a maximum infusion rate of 6 mcg per kg per hour . This was discontinued on day of life two to maintain a mean arterial pressure of greater than 33 . She has remained hemodynamically stable during the remainder of her hospitalization here . Fluids electrolytes nutrition Initially maintained NPO . UAC and UVC lines were placed upon admission to the CMED . The UAC was left in place until day of life two and was removed after wean from dopamine . UVC remained in place through day of life six and was utilized to administer parenteral nutrition . Electrolytes and glucose remained in the normal range throughout the first week . She was started on enteral feeds on day of life six with a slow advance secondary to increased abdominal girth which was felt to be due to CPAP . She passed meconium . She achieved full feeds on day of life 13 . Calories were gradually increased to breast milk 30 calories with ProMod consisting of four of human milk fortifier four of MCT and two of Polycose with a 12-28 teaspoon of ProMod per 50 ml of breast milk or 60 ml of formula . On day of life six due to concerns for hyperglycemia and abdominal distention sepsis evaluation was obtained . She was noted at this time to have hyperglycemia requiring two subcutaneous doses of insulin and a decreased glucose infusion rate to achieve euglycemia . This resolved that same day . Urine output was always noted to be of sufficient quantity . Gastrointestinal Mychelia demonstrated slow gastrointestinal motility and abdominal distention felt to be due to CPAP . She was slow to advance on enteral feeds and gradually attained full enteral volume on day of life 13 . On day of life 15 she was made NPO for a distended abdomen and a bilious spit . Serial KUBs revealed nonspecific changes with dilated loops . No pneumatosis or free air was seen . She was noted to have bluish discoloration thought to perhaps be a bruise on her left lower quadrant . There was no radiographic correlation with this . Feeds were restarted . Again she was advanced to full volume but was made NPO on day of life 20 for abdominal distention . This NPO was temporary for that day and she then resumed feedings and has been tolerating full enteral feeds well improved since off of CPAP passing normal stools guaiac negative . Mychelia was also treated for physiologic jaundice . She was started under phototherapy on day of life one through day of life three with a peak serum bilirubin of 4.7 0.3 . This issue resolved . Hematologic and Infectious Disease Initial CBC was notable for a white count of 5.5 with 49 polys 1 band and 47 lymphs . Initial hematocrit was 46.3 percent and platelets 320 000 . Her initial blood culture remained negative and she received 48 hours of ampicillin and gentamicin . As previously noted on day of life six with hyperglycemia abdominal distention a CBC and blood culture were again obtained revealing a white count of 9.1 with 30 polys 0 bands and 58 lymphs . Hematocrit at that time was noted to be 31 and platelets 370 000 . Blood culture grew staph coagulase negative and the baby received seven days of vancomycin and gentamicin . A lumbar puncture was also performed to rule out meningitis . This culture remained negative with normal cell counts and chemistries . Antibiotic levels were monitored and doses adjusted accordingly . Mychelia required two transfusions during her hospital stay . On day of life 15 for a hematocrit of 29 she received 20 cc of packed red blood cells . She started on iron and vitamin E supplements on day of life 25 and continues on that at this time of transfer . However on day of life 34 12-04 she was noted to be pale and less stress tolerant mottling easily with care . A hematocrit and reticulocyte count showed a hematocrit of 23 percent and a reticulocyte count of 1.9 percent . Therefore with blood available from the first aliquot a second 20 cc per kg of packed red blood cells were infused without incident . Neurological Initial head ultrasound on day of life seven was normal . At one month of age on 12-03 she was noted to have an absent septum pellucidum . An MRI obtained and reviewed by the Hallmark Health System Radiology Department revealed focal gyral morphology consistent with prematurity normal midline structures normal myelination no lesions no signal abnormalities or extracerebral collections . The cortical ribbon is intact . The major vascular structures at the skull base are normal . The septal leaflets may be partially absent but there are no coronal images provided for confirmation and the pituitary stalk is present . An Ophthalmology consult was obtained to determine the presence of optic nerves . These were both determined to be present and intact . Endocrine was also consulted . Several labs were ordered . Electrolytes and thyroid studies were noted to be in the normal range with serum sodium of 136 potassium 4.7 chloride 98 and CO2 34 . She had a calcium of 10.3 a phosphorus of 4.8 and alkaline phosphatase of 440 . Thyroid function studies revealed a TSH of 2.2 T4 of 5.7 T3 of 101 and a cortisol level of 43 all within the normal range . A growth hormone was sent and the results were pending at time of transfer . In addition an FSH and LH were obtained on 12-10 and results are pending at time of transfer . Please contact lab control at Mattapan Community Health Center for results 409 238-8236 . The baby s neurologic examination is appropriate for corrected gestational age which is 33 and 6 7 weeks on day of transfer . By mother s report a maternal cousin also has an absent septum pellucidum . Given normal pituitary tests thus far and normal optic nerve no evidence of septic optic dysplasia . Pediatrician should have low threshold for endocrinology reconsult if any signs of pituitary problems . Sensory Audiology hearing has not yet been obtained . This is recommended prior to discharge from hospital to home . Ophthalmology Initial ROP screen was done on 12-02 and revealed immature retinas to zone 2 bilaterally . They recommended follow-up examination due on the week of 12 20 . Psychosocial Gardner State Hospital social worker has assisted in working with this family . The contact may be reached at 754 791 7976 . Parents have been very involved and appropriate with infant and have eagerly learned to care for their baby . Condition at time of transfer is good . Discharge disposition is to level 2 nursery at Jordan Hospital Hospital . Name of primary pediatrician is Ashley Daley of Village Pediatrics in Stockbridge . Feedings at the time of transfer include breast milk 30 with ProMod at 150 cc per kg per day all gavage given over one hour . Medications include Fer-In-Norman vitamin E 5 international units each day and caffeine citrate once a day . Car seat positioning screening has not been obtained . Newborn state screens have been sent per protocol . Results have been in the normal range . IMMUNIZATIONS RECEIVED Mychelia received hepatitis B vaccine on 11-02 due to unknown maternal hepatitis B surface antigen status . She also received hepatitis B immune globulin on 11-02 . On 12-06 she received her second hepatitis B vaccine . Her two month immunizations have not yet been given . IMMUNIZATIONS RECOMMENDED Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following three criteria 1 born at less than 32 weeks 2 born at between 32 and",
"role": "user"
},
{
"content": " 35 weeks with two of the following Daycare during RSV season a smoker in the household neuromuscular disease airway abnormalities or school age siblings or 3 infants with chronic lung disease . Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age . Before this age and for the first 24 months of the infant s life immunization against influenza is recommended for household contacts and out of home caregivers . Follow-up appointments recommended with the primary pediatrician Dr. Marilyn Daley of Stockbridge Village Pediatrics Dr. Lynn Warren of Neurology from Emerson Hospital and Ophthalmology to follow her ophthalmology status . DISCHARGE DIAGNOSES Prematurity at 28-2 7 weeks . Surfactant deficiency . Hypotension . Sepsis suspect . Physiologic jaundice . Coagulase negative bacteremia . Anemia of prematurity . Apnea of prematurity . Absent septum pellucidum . Rosalie Gloria North Dakota 67177 Dictated By George D Gregory M.D. MEDQUIST36 D 2013-12-10 124122 T 2013-12-10 140332 Job <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Cardiology was consulted to evaluate this and felt that the changes seen on the EKG were not significant . The patient was also seen by Dr. Nusc from General Surgery for evaluation of micro calcifications in the right breast . The patient refused a biopsy for this admission and desires follow-up mammograms . She is to be followed up by General Surgery .",
"role": "user"
},
{
"content": " The patient underwent a total vaginal hysterectomy on June 4 1993 which she tolerated without complications . Her post-operative course has been uncomplicated . She remained afebrile throughout her admission tolerating a regular diet by post-operative day two and was discharged on June 6 1993 with Percocet for pain . The Foley was discontinued and the patient was urinating on her own . DISPOSITION <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Mr. Gach is an 80 year old man with aprevious history of coronary artery disease who was transferred from Linghs County Medical Center to Oaksgekesser Memorial Hospital because of an apparent infected wound including the PICC line in his right elbow and positive blood cultures for Staph. aureus associated with fever . He has a history of myocardial infarctions in 1981 1992 and 08 97 with thelast episode complicated by anoxic encephalopathy . He gradually improved but had recurrent angina",
"role": "user"
},
{
"content": " requiring cardiac catheterization demonstrating 90 left main 95 ostial LAD and 30 to 40 mid-LAD with an occluded RCA . CABG surgery with two vessel bypass was done on 11 18 97 . He was then transferred to Linghs County Medical Center . A PICC line was placed in his left antecubital fossa and on the day of New Years Eve he developed a fever of 102 and became lethargic . The PICC line site was erythematous . Blood cultures grew out 4 out of 4 bottles for gram positive cocci which thereafter proved to be Staph. aureus Methicillin sensitive . He had no chest pain shortness of breath or diarrhea . PAST MEDICAL HISTORY Includes ischemic cardiomyopathy with an echocardiogram done on 11 13 97 showing an ejection fraction of 28 and LV that is diffusely hypokinetic . OTHER MEDICAL PROBLEMS Dementia 2 paroxysmal atrial fibrillation 3 hypertension 4 peripheral vascular disease with previous left femoral popliteal bypass 5 diabetes mellitus 6 chronic renal insufficiency 7 COPD 8 previous abdominal aortic aneurysm repair in 1981 9 benign prostatic hypertrophy status post TURP surgery in 1982 . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "noncontributory Physical Exam Vitals T 102.8 HR 113 BP 157 85 RR 35 Sat 97 on BIPAP 10-23 Gen frail elderly caucasian man lying in stretcher HOB at 45 degrees breathing in moderate distress with accessory muscle use HEENT BIPAP mask in place with no apparent leak eyes closed mouth open no rhinorhea or oral discharge visible Neck JVP flat CV difficult to assess heart sounds over respiratory sounds but appears to have RRR nl s1 s2 no murmurs Lungs R lower 01-20 with coarse BS and rales L side clear no wheezing Abd thin nd nt soft no masses palpable Ext thin no edema multiple old well-healed scars on R leg Skin warm and dry no rash or breakdown noted though could not examine sacrum Neuro reactive to pain otherwise Pertinent Results 2014-01-20 0530 AM BLOOD WBC 10.9 RBC 4.63 Hgb 13.6 Hct 40.3 MCV 87 MCH 29.3 MCHC 33.7 RDW 14.0 Plt Ct 393 2014-01-20 0530 AM BLOOD Neuts 82.6 Lymphs 14.5 Monos 2.2 Eos 0.2 Baso 0.4 2014-01-20 0208 PM BLOOD PT 13.2 PTT 27.4 INR PT 1.2 2014-01-20 0530 AM BLOOD Plt Ct 393 2014-01-20 0530 AM BLOOD Glucose 334 UreaN 22 Creat 0.9 Na 144 K 5.0 Cl 108 HCO3 25 AnGap 16 2014-01-20 0208 PM BLOOD CK CPK 275 2014-01-20 0530 AM BLOOD ALT 15 AST 22 LD LDH 254 CK CPK 398 AlkPhos 125 TotBili 0.5 2014-01-20 0208 PM BLOOD CK-MB 9 cTropnT 0.08 2014-01-20 0530 AM BLOOD cTropnT 0.05 2014-01-20 0530 AM BLOOD CK-MB 7 2014-01-20 0530 AM BLOOD Albumin 3.2 Calcium 9.3 Phos 4.2 Mg 1.8 ABG s 2014-01-20 1046 PM BLOOD Type ART pO2 148 pCO2 129 pH 7.03 calHCO3 37 Base XS -1 2014-01-20 1149 AM BLOOD Type ART PEEP 5 FiO2 60 pO2 75 pCO2 56 pH 7.29 calHCO3 28 Base XS 0 Intubat NOT INTUBA Comment BIPAP 2014-01-20 1046 PM BLOOD Glucose 114 Lactate 1.8 K 4.8 2014-01-20 1149 AM BLOOD Lactate 3.0 K 5.1 2014-01-20 1149 AM BLOOD freeCa 1.19 CXR IMPRESSION Focal consolidation in the medial aspect of the right lower lung Brief Hospital Course This 86 yo man with h o CVA CHF recent episodes of aspiration pneumonia presented with dyspnea from his NH likely from new RLL pneumonia . He was started on Zosyn and Vanco for his presumed aspiration hospital aquired PNA . PE was considered but less likely given his fevers and clear pneumonia on CXR . He was supported on BIPAP for his respiratory status . An ABG was attempted in the Deanna however it was limited by pt discomfort . ABG on arrival to the ICU was 7.29 56 75 . He was continued on BIPAP . Blood cultures and sputum cultures were sent . Over the course of the day he continued to decline .",
"role": "user"
},
{
"content": " He was given some prn Morphine for comfort . In the evening of the day of admission he was noted to be increasingly somnolent . A repeat ABG was performed which was 7.03 129 148 . His family was notified that he was doing worse and came in to visit him . It was his family s wish that he be made comfortable . Based upon this wish the BIPAP was removed and he was placed on nasal cannula . He was written for a morphine drip however he expired before this could be initiated . Secondary issues Elevated lactate This was concerning for early sepsis given RLL PNA . His blood pressures remained elevated and he was hydrated with NS conservatively given h o CHF and dyspnea . DM2 He was covered with a Insulin drip while unstable CV CAD He was not taking any PO medications per Hunt Center Rehab so all medications were held . Medications on Admission Meds Paxil Terazosin Glucophage Glyburide Atenolol Imdur Discharge Disposition Expired Discharge Diagnosis Pneumonia Discharge Condition expired Discharge Instructions N A Followup Instructions N A Daniel Monica MD 55-804 Completed by Sheri John MD 30-456 2014-01-21 0659 Signed electronically by DR. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Lisinopril 5 mg p.o. q.d. Lopressor 25 mg p.o. b.i.d. Plavix 75 mg p.o. q.d. Lipitor 10 mg p.o. q.d. Protonix 40 mg p.o. q.d. Enteric-coated aspirin 325 mg p.o.",
"role": "user"
},
{
"content": " q.d. CONDITION AT DISCHARGE Condition on discharge was stable . DISCHARGE DIAGNOSES 1. Inferior myocardial infarction and right ventricular infarction . Status post cardiac catheterization and stents times three of the right coronary artery . Hypertension . Hypercholesterolemia . Rosemary D Mccluskey M.D. 39-696 Dictated By Harriet E. Evans M.D. MEDQUIST36 D 2011-11-22 1409 T 2011-11-23 1159 JOB 15087 Signed electronically by DR. Sandra BURGER on WED 2011-11-30 946 AM <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is a 47 year old white male with a history of emphysema who presents for admission with a diagnosis of",
"role": "user"
},
{
"content": " broncho-alveolar carcinoma and is scheduled for flexible bronchoscopy mediastinoscopy and thoracotomy with questionable pneumonectomy by Dr. An on 12-4-93 . The patient is a native of Nahuter with a 70 pack year smoking history 2 1 2-3 pack per day x 35 years whose symptoms began last 12 92 when he had a persistent cough and fever . In six months he was hospitalized for pneumonia x four . He has had worsening dyspnea and paroxysmal nocturnal dyspnea though denies orthopnea . No hemoptysis no fevers chills sweats when pneumonia resolved . The patient also noticed a loss of weight of approximately 25 pounds over a few months with increased fatigue and lower extremity weakness . A " spot " in the left lower lobe on chest X-ray was noted in October of 1993 after his pneumonia cleared . A follow up chest computerized tomography scan led to a tissue biopsy via flexible bronchoscopy in 07 93 . Tissue returned well differentiated adenocarcinoma . The patient was told nothing could be done until he was referred to Dr. An . His appetite has been good and he has only complained of occasional sharp pain under his rib cage right greater than left . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Awake alert spontaneous and appropriate and somewhat uncomfortable due to pain but looked well . She",
"role": "user"
},
{
"content": " was afebrile and had normal vital signs . The oxygen saturation was normal at 98 on room air . There was no evidence of head trauma . There was no scleral icterus . The oropharynx was clear . The neck was supple with no lymphadenopathy . The chest was clear with normal excursion . Heart was regular with no murmurs rubs or gallops . The abdomen was soft and nontender with no masses no organomegaly . The skin and extremities were normal with no cyanosis clubbing edema lesions or rashes . Neurologic examination was normal . Strength sensation coordination and cranial nerve function were all normal . Straight leg raise test was difficult to perform due to pain but seemed to be positive on the right . Psychiatric examination was normal . Examination of the back revealed lumbar tenderness with no point tenderness . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The",
"role": "user"
},
{
"content": " patient is to be transferred to the Cambridge Hospital Hospital Special Care Nursery .', <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Metastatic gallbladder cancer . Status post cholecystectomy .",
"role": "user"
},
{
"content": " Status post transverse colectomy with anastomosis . G tube placement . Feeding jejunostomy . Hypothyroidism . Blood loss requiring transfusion . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Subarachnoid hemorrhage",
"role": "user"
},
{
"content": " posttraumatic . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Methylprednisolone 4 mg q. a.m. and 2 mg p.o. q.h.s. spironolactone 50 mg p.o. q.d. metformin 1500 mg p.o. q.h.s. Pravastatin 10 mg p.o. q.h.s. lisinopril 20 mg p.o. q. a.m. Lasix 80 mg p.o. q. a.m. Tylenol",
"role": "user"
},
{
"content": " as needed insulin regular 22 units in the morning and 12 units at night lispro regular . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is allergic to sulfa . HABITS 50 pack year smoking history still smoking currently . Ethanol",
"role": "user"
},
{
"content": " none . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is a 52 year old female with gravida",
"role": "user"
},
{
"content": " 3 para 3 who presents with complains of abdominal pain and enlarged ovary by ultrasound . The patient is also complaining of several years urinary incontinence . The patient &aposs recent history is also notable for a Papanicolaou smear which revealed somomabodies . The patient also had vaginal bleeding in April 1992 following radiation therapy . The patient initially presented with hypercalcemia and underwent a parathyroidectomy on June 22 1993 . It was at that time that her abnormal Papanicolaou smear was obtained . The patient is now admitted for exploratory laparotomy . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "1 Enteric coated aspirin 325 mg p.o. q.",
"role": "user"
},
{
"content": " day . 2 Capoten 25 mg p.o. t.i.d. 3 Lanoxin 0.25 mg p.o. q. day . 4 Cardizem 125 mg p.o. q. day . 5 Glucotrol XL 10 mg p.o. b.i.d. 6 Glucophage 500 mg p.o. q. day . 7 Amaryl 2 mg p.o. q.h.s. PHYSICAL EXAMINATION Physical examination revealed that the vital signs were stable . Lungs were clear to auscultation bilaterally . Heart was irregular with no murmurs palpated . Abdomen was benign . Pulses were 2 throughout . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Factor 8 boluses at 75 units kg day . Car seat position screening passed . State Newborn",
"role": "user"
},
{
"content": " Screen sent . Immunizations Received hepatitis B vaccination on 05-16 . FOLLOW-UP APPOINTMENT Scheduled for 05-21 . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Cardiac arrest His arrest was of unknown etiology at the time of admission . No further history was ever gained about his cardiac arrest throughout his hospitalization . CT angiogram had been negative for pulmonary embolism . The patient had an echocardiogram on 2013-04-26 which showed a normal ejection fraction and trivial mitral regurgitation otherwise no obvious abnormalities were seen . Given the patient had an out of hospital arrest remained unresponsive despite hemodynamic stability he was treated with induced hypothermia and with cold packs and a cooling blanket were placed with goals of reducing his core body temperature to 32 degrees Celsius for a period of twelve hours at which point he would be rewarmed over the subsequent six hours . This was done however as in problem number two below we were not successful in any neurologic recovery . Neurology The patient",
"role": "user"
},
{
"content": " remained unresponsive after the induced hypothermia the patient was noticed to develop myoclonic jerks and occasional fluttering of his eyelids . Electroencephalogram revealed the patient was experiencing persistent seizure activity . Neurology was consulted and the patient was treated very aggressively loaded with multiple drugs including Ativan and Propofol drips . The patient continued to demonstrate seizure activity despite this . He was loaded with Dilantin and ultimately was treated with a Pentobarb coma . After multiple attempts of weaning the Pentobarb the patient was continually reverting to status epilepticus which was never able to be suppressed . Infectious disease Over the course of his hospital stay the patient s white blood cell count rose to a peak of 17 . Multiple cultures were done and the patient was ultimately found to have methicillin resistant Staphylococcus aureus bacteremia pneumonia and urinary tract infection . For all these infections the patient was treated with Vancomycin and he was also on Levofloxacin and Flagyl for presumed aspiration pneumonia at the time of his admission . Blood cultures cleared by 2013-05-03 . Sputum culture as late as 2013-05-10 however was still positive for coagulase positive Staphylococcus which was methicillin resistant Staphylococcus aureus . The patient remained gravely ill throughout his hospital stay and had multiple meetings were held with his family with his son being his next of kin . Ultimately it was decided that the patient s wishes would be to not be maintained in a vegetative state and given his poor prognosis ultimately the decision was made to pursue comfort measures only . With these goals of care the patient expired on 2013-05-11 . The family did consent to a postmortem examination . DISCHARGE DIAGNOSES Cardiac arrest . Anoxic brain injury Status epilepticus Methicillin resistant Staphylococcus aureus pneumonia . MRSA urinary tract infection . MRSA Bacteremia . Steven Welch Montana 61528 Dictated By Julie DD George M.D. MEDQUIST36 D 2013-12-24 135505 T 2013-12-24 204707 Job 52892 Signed electronically by DR. Patricia Henley on Maxine 2014-01-02 1045 AM <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "No known drug allergies . MEDICATIONS AT HOME 1. Flomax 0.4 q.d. Aspirin 325 q.d. Lipitor 10 q.d. Naproxen p.r.n. as well as several vitamins and supplements . Zestoretic with an unknown dose . MEDICATIONS ON TRANSFER 1. Captopril 25 t.i.d. Protonix q.d. 40 . Nitroglycerin paste 1 inch q. 6 hours . Lopressor 25 b.i.d. Plavix 75 q.d. Lovenox 90",
"role": "user"
},
{
"content": " b.i.d. Aspirin 325 q.d. Lipitor 10 q.d. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Atrial fibrillation 2 s p MVR mechanical 3 CHF EF 15 4 HTN 5 multiple CVA s last 1998 6 Hypercholesterolemia 7 Type II DM 8 Multiple prior",
"role": "user"
},
{
"content": " UTI Social History Lives in Danvers with wife denies Timothy or alcohol <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Lopressor 100 mg po three times a day . Captopril 75 mg",
"role": "user"
},
{
"content": " po three times a day . Prilosec 20 mg po per day . Hydralazine 12.5 mg four times per day . Reglan 10 mg po three times a day . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Notable for a sodium of 145 potassium 3.6 BUN 23 creatinine 1.3 glucose 104 hematocrit 42 white count 8.7 platelet count 235 and a PT of 12.9 seconds . The urinalysis was negative . The Troponin I was less than .4 and the creatine kinase was 114 .",
"role": "user"
},
{
"content": " Chest x-ray revealed moderate cardiomegaly with no clear interstitial or alveolar pulmonary edema and chronic atelectasis and or scarring at both lung bases . The electrocardiogram revealed normal sinus rhythm with premature atrial complexes and right bundle branch block with left anterior hemiblock and old anterior myocardial infarction . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "There is no family history of coronary artery disease . VITALS ON ADMISSION She had a temperature of 98.1 blood pressure of 130 99 pulse of 111 respiratory rate of 16 . She was saturating 100 on room air . PHYSICAL EXAM General She is in no apparent distress . She is obese . She is slightly tachypneic . HEENT Pupils are equal round",
"role": "user"
},
{
"content": " and reactive to light . Her oropharynx is clear . Mucous membranes are moist . Neck She has JVD to angle of the jaw no bruits . Chest She has got bilateral basilar crackles no wheezing . Cardiac examination She had a normal S1 S2 with a 2 6 systolic ejection murmur at the left upper sternal border . She had a positive S4 . Her abdomen was obese soft nontender . Extremities 2 edema to the knees . LABORATORIES ON ADMISSION She had a white count of 9.3 hematocrit of 37.7 platelets of 293 . She had a CK of 212 and MB of 21 and a troponin of 0.56 . She had a Chem-7 which was normal . She had an INR of 1.5 on her Coumadin . Chest x-ray showed right patchy opacity with a right effusion . EKG showed sinus tachycardia borderline left axis normal intervals LVH left atrial enlargement no Q waves no P-R depressions no ST segment elevations or depression . HOSPITAL COURSE 1. Congestive heart failure Patient was diuresed effectively with nesiritide and Lasix . Patient s weight on admission was 250 pounds and on the day of discharge was 244 pounds which was back to her dry weight . She had lost the 6 pounds that she reported gaining in the four days prior to her hospitalization . Patient was continued on her Toprol her lisinopril and her digoxin . Patient s Coumadin was held for right heart catheterization and biopsy and then EP study with ICD placement . Patient did have Woodrow Betty SPEP and anticardiolipin antibody sent for further workup of the etiology of her cardiomyopathy . The Courtney SPEP and anticardiolipin antibody were all negative . Her CKs did trend down over the course of her hospital stay and in the setting of her known clean coronaries on cardiac catheterization in 2011-11-19 it was believed that a myocarditis might be the cause of her elevated cardiac enzymes and also could have exacerbated her congestive heart failure . Patient did receive a right heart catheterization which showed elevated wedge pressures and biopsy specimens were obtained of the right ventricle . The results of these biopsies are still pending in pathology . Post right heart catheterization and right ventricular biopsy the patient was sent to the CCU for a Swan guided therapy in the setting of her elevated wedge pressures and low cardiac output . In the CCU she was put on milrinone with good results . Patient was also seen by the Pulmonary service here and had pulmonary function tests done as part of a pretransplant workup . There is no pulmonary process to exclude her from the transplant list as noted by the Pulmonary service . Patient did receive an ICD during this hospital admission without complication . Patient was in bigeminy during the course of her hospital stay and did have frequent runs of ectopy as noted on telemetry . 2. Her right lower lobe infiltrate Patient did report a cough productive of green sputum on admission . She received a full course of azithromycin for this with resolution of her cough and sputum production . On discharge the patient was restarted on her Coumadin which was held for her right heart catheterization and her biopsy and her ICD placement . She was also continued on all her heart failure medications including her Toprol her lisinopril her digoxin and her Lasix . CONDITION ON DISCHARGE Good . DISCHARGE STATUS To home . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Lisinopril 5 mg p.o. q.d. Lopressor 25 mg p.o. b.i.d.",
"role": "user"
},
{
"content": " Plavix 75 mg p.o. q.d. Lipitor 10 mg p.o. q.d. Protonix 40 mg p.o. q.d. Enteric-coated aspirin 325 mg p.o. q.d. CONDITION AT DISCHARGE Condition on discharge was stable . DISCHARGE DIAGNOSES 1. Inferior myocardial infarction and right ventricular infarction . Status post cardiac catheterization and stents times three of the right coronary artery . Hypertension . Hypercholesterolemia . Rosemary D Mccluskey M.D. 39-696 Dictated By Harriet E. Evans M.D. MEDQUIST36 D 2011-11-22 1409 T 2011-11-23 1159 JOB 15087 Signed electronically by DR. Sandra BURGER on WED 2011-11-30 946 AM <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "She is on Lasix 40 mg p.o. b.i.d. Aldactone 25 mg p.o. b.i.d. Prilosec 20 mg p.o. daily ciprofloxacin 250 mg p.o. daily this is for prophylaxis for cholangitis and iron . Discharge Medications 1. Pantoprazole Sodium 40 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO Q12H every 12 hours . Disp 60 Tablet Delayed Release E.C. s Refills 2 2. Furosemide 40 mg Tablet Sig One 1 Tablet PO BID 2 times a day . Disp 60 Tablet s Refills 2 3. Spironolactone 25 mg Tablet Sig One 1 Tablet PO BID 2 times a day . Disp 60 Tablet s Refills 2 4. Levofloxacin 500 mg",
"role": "user"
},
{
"content": " Tablet Sig One 1 Tablet PO Q24H every 24 hours . Disp 30 Tablet s Refills 0 5. Ursodiol 300 mg Capsule Sig One 1 Capsule PO TID 3 times a day . Disp 90 Capsule s Refills 2 6. Prochlorperazine 10 mg Tablet Sig One 1 Tablet PO Q6H every 6 hours as needed . Disp 30 Tablet s Refills 0 7. Nystatin 100 000 unit mL Suspension Sig Five 5 mL PO four times a day Swish and swallow . Disp qs mL Refills 2 8. Nadolol 20 mg Tablet Sig One 1 Tablet PO once a day . Disp 30 Tablet s Refills 2 9. Outpatient Lab Work Please have CBC and alkaline phosphatase and total bilirubin checked on Monday 11-04 Discharge Disposition Home with Service Discharge Diagnosis Cholangiocarcinoma Biliary obstruction Grade III esophageal varices Discharge Condition Stable . Discharge Instructions Call your primary care doctor oncologist or return to the Emergency Room if you have increasing nausea vomiting leg swelling confusion or pain . Followup Instructions Please follow up at all scheduled appointments including Wednesday in IR clinic . Call the IR clinic on Monday to confirm your appointment 236 672 0628 . Ask to speak with May Chen PA. Call your primary care doctor Joanne Dennen for follow up appointments . You will have a banding procedure in 9 days . Please call the GI clinic and arrange to see Dr. Langton for an appointment 232-2590 . Ronald Donna MD 19-658 Completed by Neal Robert MD 12-904 2013-11-04 1405 Signed electronically by DR. Wilson J. Sanchez on WED 2013-11-13 905 AM <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Percocet 1 -2 PO q4h",
"role": "user"
},
{
"content": " prn . FOLLOW UP He will be followed up in Cesa New York . DISPOSITION On discharge he is mobilized partial weight bearing with the help of a walker . The condition on discharge is good . STA AGE M.D. DICTATING FOR SHAA STONGE M.D. TR <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Mr. Breath was a 32 year old previously healthy unbelted driver whose car was hit at high speed by a vehicle driven by an intoxicated driver . The patient was ejected and his vehicle rolled over possibly over him . He was found awake at the scene complaining of abdominal pain . He had a blood pressure of 60 systolic upon arrival of the Giles Min General Hospital crew . Intravenous fluids was given . He was paralyzed and endotracheally intubated and a 14 gauge catheter was inserted in his left chest because of poor breath sounds . He arrived at the Fairm of Ijordcompmac Hospital at 0230 with a blood pressure of 86 and a heart rate of 170 . Large bore cannulas were inserted into the femoral veins bilateral chest tubes were placed and his blood pressure rose to 110 systolic after two liters of crystalloid . He had an ecchymosis over the medial right costal margin and his abdomen was distended . His hematocrit was 36 and creatinine 1.6 . The abdominal tap was grossly positive for blood . His blood pressure fell to 60 systolic as he was being transferred to the computerized tomography scan table the scan was aborted and he was taken directly to the operating room at 0300 . At laparotomy there was a liter of blood in the peritoneal cavity . There was a class II laceration of the left liver at the falciform ligament which was actively bleeding a tear of the transverse mesocolon from its base to the bowel wall with active bleeding a 7 cm serosal tear of the adjacent transverse colon and a large central retroperitoneal hematoma . Control of the super-celiac aorta was obtained and both left and right sided " Mattox " maneuvers were performed . The retroperitoneum was opened with vigorous bleeding resulting . This was controlled necessitating ten minutes of aortic clamping and found to have originated from the rupture of the left renal vein one centimeter from its junction with the inferior vena cava . The vein was divided and suture ligated . Bleeding from the liver was controlled with sutures . The tears in the transverse mesocolon and colon serosa were repaired . The examination of the remainder of the abdominal contents revealed no other injury in particular the entire anterior surface and the immediately juxtaduodenal posterior surface of the pancreas were normal . The patient was now very stable and he was taken to the Respiratory Intensive Care Unit . The patient had received ten units of packed red blood cells five units of fresh frozen plasma seven units of platelets and nine liters of Ringer &aposs lactate . An intracranial pressure monitoring bolt had been placed by the Neurosurgery Service staff during the laparotomy . Intracranial pressures were normal . That day cranial computerized tomography scan and cervical spine films were normal . An arch aortogram was normal . Over the ensuing twenty-four hours bilateral infiltrates on chest X-ray with poor oxygenation and labile blood pressure requiring PA line guided fluid and pressors developed . The patient had a large fluid requirement with total body capillary leak decreasing SVR oliguria unresponsive to Lasix Mannitol accompanied by a rise in creatinine to 3.2 worsening ARDS a rise in temperature to 103 and a serum amylase of 1265 . He was returned to the operating room on July 4 . Three liters of clear green fluid were found in the abdominal cavity . Exploration of the pancreas revealed a posterior fracture a the superior mesenteric vessels . Because of the intense diffuse inflammatory reaction that had already set in it was decided that neither distal pancreatic resection nor Roux-en-Y drainage was feasible . Four large flat Jackson-Pratt drains were placed and gastrostomy jejunostomy and cholecystostomy tubes as well as a right subclavian Quinton catheter were placed . The patient &aposs hemodynamics had improved markedly with the evacuation of the peritoneal pancreatic fluid so that he was no longer on pressors . However upon transfer from the operating room table to the RICU bed he suffered a cardiac arrest which upon investigation was a primary respiratory arrest the initial arterial blood gas was 32 88 6.92 . He was successfully resuscitated after fifteen minutes of cardiopulmonary resuscitation and he was taken to the RICU . Continuous venovenous hemodialysis was started on July 5 and continued for most of the remainder of the patient &aposs course . Vancomycin Flagyl and Aztreonam were given for gram negative Coccobacilli later identified as Bacteroides that had grown in his blood cultures and gram negative rods Enterobacter in his peritoneal fluid . He was kept sedated and paralyzed because of his severe adult respiratory distress syndrome . Total parenteral nutrition was started on July 5 . Initial improvement was followed by recurrence of low SVR high cardiac output ongoing acidosis requiring norepinephrine infusion in the 30 to 40 mcg per minute range drainage from the Jackson-Pratt drains were minimal despite irrigation and manipulation . The patient was returned to the operating room on July 10 where several loculated thin fluid collections were drained and obviously necrotic tissue was debrided . It was decided to place more drains and pack the lesser sac with Adaptic and laparotomy pads . The abdomen was left open with the wound margins connected by a sheet of Marlex mesh to prevent evisceration . He was returned to the operating room on July 12 13 16 19 21 and 23 for packing change irrigation and debridement . Tracheostomy was also performed on",
"role": "user"
},
{
"content": " July 17 . There was severe diffuse peritonitis with intense inflammation infection and patchy necrosis of peritoneal surfaces and of the distal pancreas . The subsequent overall course was a slow downhill one with ongoing extreme hyperdynamic cardiac output 12 to 15 liters per minute and catabolic state . On July 26 abdominal irrigation and debridement was performed in the RICU this was repeated daily for the next three days . On July 29 the septic state with low SVR and acidosis accelerated beyond the control of maximal support . His blood pressure gradually fell and he died early on July 30 1993 . <NOTE_END>",
"role": "assistant"
}
] |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.