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<topics>
<topic number="1" type="diagnosis">78 M w/ pmh of CABG in early [**Month (only) 3**] at [**Hospital6 4406**]
(transferred to nursing home for rehab on [**12-8**] after several falls out
of bed.) He was then readmitted to [**Hospital6 1749**] on
[**3120-12-11**] after developing acute pulmonary edema/CHF/unresponsiveness?.
There was a question whether he had a small MI; he reportedly had a
small NQWMI. He improved with diuresis and was not intubated.
.
Yesterday, he was noted to have a melanotic stool earlier this evening
and then approximately 9 loose BM w/ some melena and some frank blood
just prior to transfer, unclear quantity.</topic>
<topic number="2" type="diagnosis">Ms [**Known patient lastname 241**] is a [**Age over 90 2398**] year old woman with past medical history significant for hypertension, severe aortic stenosis, hyperlipidemia, arthroplasty.
.
Per the patient, she was standing and felt a snap of her right leg and fell to the ground.
No head trauma or LOC. She was evaluated by orthopedics and transferred to
medicine for optimization of her cardiac status.
Review of systems:
Ear, Nose, Throat: Dry mouth
Cardiovascular: Edema, Orthopnea
Respiratory: Dyspnea
Flowsheet Data as of [**3294-3-6**] 10:33 PM
Vital Signs
Hemodynamic monitoring
Fluid Balance 24 hours Since [**96**] AM
Tmax: 37.5 C (99.5)
Tcurrent: 37.5 C (99.5)
HR: 102 (93 - 102) bpm
BP: 117/54(70) {117/54(70) - 117/54(70)} mmHg
RR: 24 (15 - 24) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
.
-- Clarify She appears comfortable with adequate pain
control with prn morphine. Given her tight valvular stenosis,
she is high risk for general anesthesia.
- would start standing tylenol 1g q8
- continue morphine IV prn for breakthrough
- plan for OR tomorrow am per ortho pending optimization of her cardiac
function, and improvement in renal function
.
# CAD: No clear documentation, however given age calcific
atherosclerosis is highly likely
-- continue statin
-- Hold beta blocker for now
-- hold aspirin in perioperative period
.
# ATRIAL FIBRILLATION: In setting of acute pain and peri-op. Will need
to monitor as pt with high CHADS score, however in periop period would
not be able to have systemic anticoagulation
-- Rate control with beta blocker once stable
-- If unstable, would use esmolol first, cardiovert last option.
.
# HTN: Better controlled on floor. Good BP control essential for
preventing flash pulmonary edema in setting of AS.
- continue metoprolol, as above
- continue to monitor BP and consider adding another [**Doctor Last Name **] such
as amlodipine 5mg daily if BP sustains above SBP 150s
.
# Hyperlipidemia
- continue simvastatin 40mg PO daily
.
# FEN/GI: Low sodium diet, replete lytes PRN
.
# CODE: Confirmed DNR/DNI</topic>
<topic number="3" type="diagnosis">Pt is a 75F with a PMHx significant for severe PVD, CAD, DM, and CKD
who presented to [**Hospital1 **]-[**Location (un) 1375**] on [**6-25**]
after being found down unresponsive at home. She was found to be hypoglycemic
to 29 with hypotension and bradycardia.
Her hypotension and confusion improved with hydration.
She had a positive UA which eventually grew klebsiella, treated
initially with levofloxacin. She had a leukocytosis to 18 and a
creatinine of 6 up from presumed prior baseline of ~2. On morning of
transfer, pt had blood cultures result 3/3 bottles positive for GAS,
her antibiotics were switched to vancomycin which was then changed to
ceftriaxone. Her blood pressure dropped to the 60s. She was given a
bolus of bicarb and transfered to their ICU. After an additional bolus
of 500cc she was started on levophed. She was anuric throughout the
day. She had a midline placed on right side. She received 80mg IV
solumedrol this morning in the setting of low BPs and rare eos in
urine.
On arrival to the MICU pt was awake but drowsy. She was receiving
levophed throughout her transfer. Arrival VS: 96.3 68 102/26 22 97% 2L
NC on 0.04mcg/kg/min levophed. On ROS, pt denies pain,
lightheadedness, headache, neck pain, sore throat, recent illness or
sick contacts, cough, shortness of breath, chest discomfort, heartburn,
abd pain, n/v, diarrhea, constipation, dysuria. Is a poor historian
regarding how long she has had a rash on her legs. States she has not
felt ill and she was brought to the hospital because her daughter came
home and found her sleeping. Does complain of feeling very thirsty."</topic>
<topic number="4" type="diagnosis">The patient is an 87 yo woman with h/o osteoporosis, multiple recent
falls, CAD, who presents from nursing home with C2 fracture and
evidence of pulmonary emoblus. The patient was in her usual state of
health at her nursing home until yesterday morning when she sustained a
fall when trying to get up to go to the bathroom. The fall was not
witnessed, but the patient reportedly did not lose consciousness. At
3:30 that afternoon, the patient complained of neck and rib pain. She
was taken to OSH, where she was found to have a comminuted fracture of
C2. She was transferred to [**Hospital1 1**] for further evaluation. Of note, the
patient was recently treated for CDiff infection at her nursing
facility, per discussion with her daughter.
.
In the ED, the patient's VS were T 99.1, BP 106/42, P 101, R 24. She
had an ECG which showed sinus tachycardia and ST depressions in V3 and
V4. CT head was negative for ICH. She was seen by Trauma surgery, who
recommended stabalization with a cervical collar for the next six to
eight weeks, but they deemed that she is not an operable candidate.</topic>
<topic number="5" type="diagnosis">An 82 M with COPD, s/p bioprosthetic AVR for AS, afib s/p CV, right
nephrectomy for RCC, colon ca s/p colectomy who presents with 9 day
hostory of productive cough and fevers.light of stairs baseline.
dyspnea and productive cough of several weeks. Otherwise patient is
without any complaints
In the ED, initial vs were: 80, sbp 100, mid 90s on 6L/NC. Last vital
signs prior to ER transfer were 98.1, 83, 116/40, 20, 95% on 3L/NC.
Patient looked comnfortable. 90% room air, INR 8, ABG, ARF, 2 liters
ivf. guiac + brown, got levo, ceftriaxone.
Physical Examination
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), (Murmur:
Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :
RLL, Wheezes : diffuse)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower extremity
edema: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Normal</topic>
<topic number="6" type="diagnosis">This is a [**Age over 90 **] year old female with hx recent PE/DVT, atrial
fibrillation, CAD who is transfered from [**Hospital3 915**] Hospital for
ERCP. She has had multiple admissions to [**Hospital3 915**] this past month,
most recently on [**2963-11-24**]. In early [**Month (only) 776**], she presented with back
pain and shortness of breath. She was found to have bilateral PE's and
new afib and started on coumadin. Her HCT dropped slightly, requiring
blood transfusion, with guaic positive stools. She was discharged and
returned with abdominal cramping and black stools. She was found to
have a HCT drop from 32 to 21. She was given vit K, given a blood
transfusion and started on protonix. She received an IVF filter and
EGD. EGD showed a small gastric and duodenal ulcer (healing),
esophageal stricture, no active bleeding. She also had an abdominal
CT demonstrating a distended gallbladder with gallstones and biliary
obstruction with several CBD stones.
Since 12 AM
Tmax: 38 C (100.4
Tcurrent: 37.4 C (99.4
HR: 92 (83 - 94) bpm
BP: 89/32(54) {89/32(54) - 94/37(60)} mmHg
RR: 23 (23 - 33) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)</topic>
<topic number="7" type="diagnosis">Mr. [**Known patient lastname 7952**] is a 41 yo M with PMH ETOH abuse, cholelithiasis, HTN,
obesity who presented to [**Hospital3 **] with hematemasis. He reports
that for the past 6 years he has been drinking [**2-9**] of a 1.7L bottle of
vodka daily. On Friday evening he had several episodes of vomiting of
bright and dark red material for which he presented to [**Hospital1 **].
He had an NG tube which reportedly failed to clear with
lavage and patient self d/c'd the NGT because he was vomiting around
the tube. He was given 4mg IV morphine for abdominal pain, ativan 2mg
IV for withdrawal, protonix 40mg IV, zofran 8mg IV, octreotide 50mcg
IV, and 1 unit of platelets.
In the ED, initial vs were: T 98.6 P66 BP145/89 R16 O2 sat 98% RA. He
was started on a protonix gtt and octreotide gtt given his elevated
LFT's. He was also given a bananna bag. He had a RUQ ultrasound which
demonstrated gallstones and sludge and per ED resident report ascites.
As such given new ascites and abdominal pain he was given levofloxacin
750mg IV and flagyl 500mg IV reportedly for SBP prophylaxis. He was
evaluted by GI in the ED.
.
On the floor, he reports that he had two episodes of vomiting of dark
red emesis. Per his nurse it was about 75ml and was gastrocult
positive. He otherwise endorese RUQ pain radiating to his back. He
also reports slow increase in abdominal girth with more acute
distention and lower extremity swelling over the two days prior to
admission.
Physical Examination
Vitals: BP:153/92 P:64 R: 20 O2: 97% RA
General: Alert, oriented, no acute distress, no asterixis
HEENT: Sclera icteric, dry mucous membranes
Neck: supple, obese, JVP not elevated
Lungs: bibasilar crackles, no wheezes
CV: Regular rate and rhythm, [**3-16**] soft nonradiating systolic murmur
Abdomen: obese/distended, RUQ and epigastric tenderness to palpation,
normoactive bowel sounds, no rebound or guarding.
Ext: warm, well perfused, 1+ pitting edema bilaterally, 2+ pulses
Labs
WBC
2.5
Hct
36.2
Plt
28
Cr
0.5
Glucose
111
Other labs: PT / PTT / INR:19.1/31.6/1.7, ALT / AST:37/165, Alk Phos /
T Bili:130/6.9, Amylase / Lipase:145/288, Albumin:2.5 g/dL, LDH:278
IU/L, Ca++:7.9 mg/dL, Mg++:1.7 mg/dL, PO4:3.0 mg/dL</topic>
<topic number="8" type="diagnosis">Ms. [**Known patient lastname **] is a G2P0010 26 yo F, now estimated to 10 weeks pregnant. Pt has 4yr hx of IDDM. LMP is not known but was sometime in [**Month (only) **].
On [**3243-11-10**], the patient began feeling achy and congested. She
had received a flu shot about 1 week prior. She continued to
feel poorly on [**3243-11-11**], and developed hyperemesis. She was seen
in the ED (but not admitted) at [**Hospital3 **], where she was
given IVF, Reglan and Tylenol and she was found to have a
positive pregnancy test. Today, she returned to the ED
with worsening of symptoms. She was admitted to the OB service
and given IVF and Reglan. Of note, her labwork
demonstrates a blood glucose of 160, bicarbonate of 11, beta-hCG
of 3373 and ketones in her urine. Her family noted
that she was breathing rapidly and was quite somnolent.
She appears to be in respiratory distress.
.
The falling beta-HCG and trans-abdominal ultrasound indicate
intra-uterine fetal demise.
Medications on Admission:
Lantus 65 units qAM
Novolog SSI
Cortef 3mg qAM, 1mg qHS
.
Meds on Transfer:
Levophed
Dopamine
Solumedrol 80mg IV
Amiodarone load
Insulin in D10</topic>
<topic number="9" type="diagnosis">Infant is a 24 [**1-31**] week, 678 gm male triplet II who was admitted to the NICU for management of extreme prematurity.
Infant was born to a 34 y.o. G2P0 now 3 mother. Prenatal screens: O+, antibody negative, HBsAg negative, RPR NR, RI, GBS unknown. IVF pregnancy notable for bleeding in the first trimester, cerclage placement at 19 weeks, and premature rupture of membranes on [**3435-11-28**] am.
Mother presented to [**Hospital1 53**]. Betamethasone given [**11-28**] at 0640. Also started on ampicillin, gentamicin, and magnesium sulfate. Mother's labor progressed despite magnesium and she developed chills and a fever (Tm 101.2). Due to progressive labor and concerns for infection, decision made to deliver infants.
Delivery by Cesarean section. Infant intubated in the Delivery Room and Apgars were 5 at one and 8 at five minutes.
Infant transported to NICU.
Exam:
VS per CareView, of note has required several boluses of NS for low BP.
Exam notes recorded on newborn examination form.
Growth measurements: Wt 678 = 25%.
-- Resp: Infant placed on SIMV. Rec'd 1 dose of surfactant.
CXR FINDINGS: There are diffuse bilateral opacities within the lungs, left greater
than right, with increased lung volumes.
No pleural effusion or pneumothorax. An endotracheal tube is
seen with tip approximately one vertebral body above the carina. An umbilical
vein catheter is seen with tip in the superior vena cava and an umbilical
artery catheter is seen with tip in the mid-thoracic region.
The imaged portions of the abdomen show a few [**Last Name (un) 36399**]-filled loops of bowel
within the left abdomen. No abnormal soft tissue mass or calcifications. No
free interperitoneal air. The imaged bony structures are unremarkable.</topic>
<topic number="10" type="diagnosis">The patient is a 55-year-old woman with hepatic sarcoidosis and
regenerative hyperplasia s/p TIPS [**10/3245**] placed [**1-27**] variceal bleeding
and portal hypertensive gastropathy s/p TIPS re-do with angioplasty and
portal vein embolectomy, who was brought to the ED by her husband for
evaluation after he noted worsening asterixis. While in the waiting room
the pt became more combative and then unresponsive.
In the ED: VS - Temp 97.9F, HR 115, BP 122/80, R 18, O2-sat 98% 2L NC.
She was unresponsive but able to protect her airway and so not
intubated. She vomited x1 and received Zofran as well as 1.5 L NS. Labs
were significant for K 5.5, BUN 46, Cr 2.2 (up from baseline of 0.8),
and ammonia of 280. Stool was Guaiac negative. A urinalysis and CXR
were done and are pending, and a FAST revealed
hepatosplenomegaly but no intraperitoneal fluid.
On arrival to the ICU the pt had another episode of emesis. NGT was
placed to suction and 1.5L bilious material was drained.
Allergies:
Cipro (Oral) (Ciprofloxacin Hcl)
Hives;
Doxycycline
Hives; hallucin
Paxil (Oral) (Paroxetine Hcl)
hair loss;
Quinine
Rash;
Compazine (Injection) (Prochlorperazine Edisylate)
muscle spasm;
Levaquin (Oral) (Levofloxacin)
tendinitis of t
Lithium
Hives;</topic>
<topic number="11" type="test">Mr. [**Name13 (STitle) 5827**] is an 80yo M with dementia, CAD s/p CABG in [**3420**] (LIMA-LAD,
SVG to OM2, SVG to RPDA), then s/p CABG redo in [**3426**], then s/p 2 caths
this year with patent LIMA, totally occluded SVG to RPDA, SVG to OM2,
s/p BMS to LCX on [**1-26**] who presented to [**Hospital3 53**] Hospital
with increasing chest pain and nausea over the past few days.
.
Per report, patient has presented several times since last cathed for
recurrent angina. Admitted to [**Hospital3 **] on [**3436-4-2**] with recurrent chest pain. Ruled out for MI. Last episode of chest pressure was the morning of transfer, associated with dry heaves and belching relieved with
morphine. Pt was continued on ASA, Plavix, Statin, BBker, Imdur and
placed on Heparin gtt. Cath last [**Month (only) **] here at [**Hospital1 5**] showed a patent BMS in LCX and no new lesions. According to the
family he usually has angina once every day or two, but for the past 2
weeks he has been having angina with any minimal exertion (eg putting
on his shirt), and waking him several times per night.</topic>
<topic number="12" type="test">66 yo female pedestrian struck by auto. Unconscious and unresponsive
at scene. Multiple fractures and complication secondary to the primary
injury. S/p embolization of the avulsed second branch of brachial
artery, complicated by exp lap secondary to suspicion of abdominal
compartment syndrome. Not much of the response after weaning the
sedation but with minimal improvement with CT of the head showing with
extensive interparenchymal hemorrhages throughout Tmax: 34.4 C (93.9
T current: 34.4 C (93.9
HR: 71 (71 - 88) bpm
BP: 171/82(120) {158/74(113) - 171/83(122)} mmHg
RR: 24 (10 - 24) insp/min
SPO2: 99%
Heart rhythm: SR (Sinus Rhythm)</topic>
<topic number="13" type="test">Ms [**Known patient lastname 21112**] is a 43 year old woman with history of transverse
myelitis leading to paraplegia, depression, frequent pressure
ulcers, presenting with chills and reporting she felt "as if
dying". Upon presentation, she denied any shortness of breath,
nausea, vomiting, but did report diarrhea with two loose bowel
movements per day. Patient reported that she had a fallout with
her VNA and has not had any professional wound care since early
[**Month (only) 51**].
Patient has a long history of psychiatric and behavioral
problems. [**Name (NI) **] [**Name2 (NI) **] review, patient was dismissed from the [**Company 110**]
practice due to abusive behavior against staff. She does not
have a primary care provider at this time.
In the ED: Temp 98.9 HR: 90 BP: 109/62 RR: 16 O2 Sat: 97%
RA. Patient initially thought to be agitated yelling her EMS
transporters were "white devils". Patient kept in observation
area, although with rigors, complaining of feeling cold and back
pain. Patient rolled and found to have a stage IV decubitus
ulcer on coccyx and buttocks, heels.
==================
ADMISSION LABS
==================
[**3266-8-26**] 01:50PM BLOOD WBC-10.3 RBC-4.98 Hgb-8.1* Hct-30.7*
MCV-62* MCH-16.2*# MCHC-26.3* RDW-17.5* Plt Ct-914*
[**3266-8-26**] 01:50PM BLOOD Neuts-89.0* Bands-0 Lymphs-9.9*
Monos-0.8* Eos-0.3 Baso-0.1
[**3266-8-26**] 01:50PM BLOOD PT-15.6* PTT-32.8 INR(PT)-1.4*
[**3266-8-26**] 01:50PM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-135
K-4.9 Cl-102 HCO3-18* AnGap-20
[**3266-8-26**] 01:50PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3
[**3266-8-26**] 04:00PM BLOOD Lipase-17
[**3266-8-26**] 01:56PM BLOOD Lactate-6.3*
[**3266-8-26**] 04:12PM BLOOD Lactate-2.9*
[**3266-8-26**] 06:17PM BLOOD Lactate-1.6</topic>
<topic number="14" type="test">A 52 year old woman with COPD and breast cancer who presented to an OSH
with SOB and back pain for several weeks. Had been seen by PCP for the
back pain and treated with pain meds. Subsequently developed rash that
was thought to be zoster. In the last few days, increased O2
requirement (2 liters at baseline --> 4 liters), cough, fevers and sore
throat. Noted sat of 79% with ambulation at home.
At OSH, diagnosed with "multi-focal pneumonia." In the process of
obtaining a CT scan, had contrast infiltrate her arm with skin
blistering and swelling. Treated with ceftriaxone and transferred to
[**Hospital1 1**].
Patient admitted from: Transfer from other hospital
History obtained from Patient, Medical records
Physical Examination
General Appearance: Well nourished, No(t) Anxious, sleepy
Eyes / Conjunctiva: PERRL, No(t) Sclera edema
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: No(t) Symmetric), (Breath Sounds:
Wheezes : expiratory, Diminished: ), scoliotic, can feel ribs on the
back on the right move with breathing
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, Clubbing
Musculoskeletal: No(t) Unable to stand
Skin: Not assessed, No(t) Jaundice, resolving zoster rash on right
lateral chest, right arm is wrapped
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): person/place/time but sleepy, Movement: Not
assessed, Tone: Not assessed</topic>
<topic number="15" type="test">Mr. [**Known patient lastname 3887**] is a 67 y.o. M with end stage COPD on home O2 3 L NC,
tracheobronchomalacia s/p Y-stent, s/p RUL resection for squamous cell
carcinoma with Cyberknife treatment in [**2764**]. Patient had Y-stent placed
in [**2769-1-1**] complicated by cough and copious secretions requiring
multiple therapeutic aspirations. Last bronchoscopy was [**5-/2769**] at OSH,
where patient had copious secretions that were aspirated. Pt reports
compliance with Mucomyst nebs and Mucinex. He wears O2 "almost" 24
hours/day, but always at night. He does not wear his CPAP. Endorses
inability to expectorate secretions and having "full feeling" for [**1-7**]
weeks. Decreaed appetitie, 50 lb wt loss in 6 months. Decreased
activity tolerance. Smokes 5 cig/day. PET scan in [**6-12**] revealed FDG
avid soft tissue mass adjacent to RUL resection site with some FDG avid
nodes concerning for recurrence.
On arrival to [**Hospital1 17**], vitals were T98.6 HR86 BP106/78 O289. Pt denied
chest pain, palpitations, trauma, F/C, N/V/D. R shoulder full PROM,
limited abduction on active ROM.</topic>
<topic number="16" type="test">The patient is a [**Age over 90 **] year old woman who was recently
hospitalized for legionella PNA, and has been continuing her
recovery at home with her son. She had been doing fairly well
for the last few days except for some waxing and [**Doctor Last Name 279**]
confusion, and perhaps intermittent dysarthria.
The son was getting ready for work at 1:15am today, as per his
usual routine. He looked in on the patient at that time; she
appeared to be sleeping comfortably in bed, on her back. Soon
thereafter, he heard her walking to the bathroom. At 1:40am, he
heard a loud crash coming from the bathroom. He found the
patient on the floor of the bathroom, making non-verbal
utterances and with minimal movement of the right side. The glass
holder which held the toothbrushes was shattered on the floor.
The son called EMS.
HEENT: Eyes closed, non-responsive to verbal stimuli,
non-verbal, grimaces on sternal rub
Cranial Nerves: Pupils equally round and reactive to light, 3
to 2 mm
bilaterally. Eyes closed, left gaze preference, normal doll's,
corneal intact, R facial weakness, tongue was midline
Motor: spontaneous movement L side; triple flexion on R side. No
anti-gravity movement.
Sensation: Winces to noxious stimuli on the right. Withdraws to
noxious stimuli on the left
Upgoing toe on R
Coordination: unable to test
Gait: unable to test</topic>
<topic number="17" type="test">This is a 76-year-old female with pmh of diastolic CHF, atrial
fibrillation on coumadin, presenting with Hct 16.9 and shortness
of breath. She had routine labs drawn yesterday at her PCP's office. Once her hematocrit came she was called and instructed to come to the ED. She is also reporting progressive shortness of breath worse with exertion over the past two weeks. She denies fevers, chills, chest pain, palpitaitons, cough,
abdominal pain, constipation or diahrrea, melena, blood in her stool, dysuria, rash. She reports orthopnea.
In the ED: vitals were 98.4 131/49, 60 24 100% 2L. ekg with NSR, twi in V1, no significant change from previous. Repeat CBC showed Hct 16.1
with haptoglobin < 20, and elevated LDH to 315. In addition, her guaiac
was reported as being positive.
Past medical history:
Hypertension
Atrial flutter/fibrillation, s/p cardioversion [**2797-1-27**]
Diastolic heart failure
Hysterectomy
Bilateral hip replacements
Social History:
Married for 53 years with four children. She is retired
from the airport. She does not smoke or drink.
Occupation: retired from airport
Drugs: denies
Tobacco: denies any history
Alcohol: denies</topic>
<topic number="18" type="test">40 year old woman with a h/o alcoholism c/b
DTs/seizures 2 years ago, polysubstance abuse including IV heroin,
cocaine, crack (last use 2 years ago), heroin inhalation (last use 2
days ago), hep C, presents for voluntary admission for detox. The
patient would like to undergo detoxification so she can take care of
her children. She also complains of abdominal pain, [**12-24**], lower
quadrants, radiating to the back since yesterday. She cannot describe
any relationship with food as she has not eaten anything. She says the
pain has worsened since yesterday. She also complains of nausea,
vomitting (bilious but nonbloody), and diarrhea (no black or red
stools). Her last drink was 9am on [**3154-2-15**]. Recently stopped her
methadone 1 week ago in an effort to quit drug abuse.
.
In the ED she was 98.6 101 149/96 20 96. She was [**Doctor Last Name 2062**] 16-25 on CIWA.
ROS:
(+)
Reports DOE, orthopnea. Also describes weight gain since given birth to
her child 17 months ago, she attributes this to her recent pregnancy.
She complains of tremors and also complains of a moderate headache
that's been stable.
.
(-)
Denies CP, fevers, chills, or cough, palpitations, edema, joint pains,
rashes, AVH, SI, or HI.
Past Medical History:
-Alcoholism (drinks baseline 1 pint of liquor/day, past week drinking 1
liter of vodka/day)
-Polysubstance abuse - including cocaine, IV heroin, and crack 2 years
ago, snorting heroin 2 days ago.
-Hep C, never treated, unknown severity, genotype, etc
-Infectious endocarditis in her 20s, 6 wks of abx no surgeries
-No h/o STDs, HIV neg 3 weeks ago
-Hep B immunized
Family History:
Alcoholism in mother, father, and sister. Father also used cocaine and
sister also used ecstasy.
Occupation: Formerly worked at Investment Firm Quality Control Dept
Physical Examination
Vitals: T: 99.6 BP: 152/96 P: 99 R: 27 O2: 99%RA
General: Alert, oriented x3, anxious, labile with at times
inappropriate laughter mixed with anxiety, obese woman.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess given habitus
Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffuse tenderness to palpation, obese, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly. During the exam she complains of severe tenderness but a
few minutes later is laughing and sitting comfortably in bed.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema
Labs
PT / PTT / INR:13.7/29.4/1.2, ALT / AST:106/249, Alk Phos /
T Bili:145/3.0, Amylase / Lipase:135/221, Differential-Neuts:57.3 %,
Lymph:34.1 %, Mono:7.0 %, Eos:0.8 %, Lactic Acid:1.8 mmol/L,
Albumin:4.1 g/dL, LDH:329 IU/L, Ca++:8.2 mg/dL, Mg++:1.7 mg/dL, PO4:2.5
mg/dL</topic>
<topic number="19" type="test">78 year old female with PMHx HTN, dCHF, Diabetes, CKD, Atrial
fibrillation on coumadin, ischemic stroke, admitted after
presenting to cardiology clinic today with confusion and
Somnolence. Of note, she was recently discharged at the
beginning of [**2876-4-14**] after presyncope/falls. At that time,
lasix was stopped and atenolol was switched to metoprolol as
there was concern that blunting of tachycardia could be
contributing to falls. She was discharged to rehab (previously
living at home).
Per report from the ER, patient has had confusion at home x 3
weeks, though no family accompanies her to corroborate this
story, and patient denies this. The patient is not sure why she
is in the hospital. She saw her cardiologist today, who
referred her to the ER after she appeared to be dehydrated,
somnolent, and confused.
The patient denies headache, blurry Vision,
numbness, tingling or weakness. No CP. +SOB, worsening DOE.
No nausea, vomiting.
Physical Exam:
GENERAL: Intubated, NAD
HEENT: Normocephalic, atraumatic. No scleral icterus. MMM, OP
clear.
CARDIAC: irregularly irregular. Normal S1, S2. No murmurs, rubs
or [**Last Name (un) 597**].
LUNGS: CTAB
ABDOMEN: Soft, NT, ND. +BS
EXTREMITIES: 1+ edema
NEUROLOGIC:
Mental status: Intubated, off sedation, minimal arousal to
voice/stimulation. Not following commands.
Cranial nerves: Pupils sluggishly reactive, both post-surgical,
R 4->3, L 3.5->3. Gaze midline and conjugate, face appears
symmetric.
Motor: Withdraws LUE and LLE weakly, no response RUE, triple
flexion RLE.
Sensory: withdraws to noxious stimulation weakly as above, L>R
Coordination: unable to assess
Gait: unable to assess</topic>
<topic number="20" type="test">This is a 87 year old female NH resident with a history of chronic atrial
fibrillation, hypertension and hypothyroidism who presents to the
[**Hospital Unit Name 10**]. She had been in her usual state of health until 5
days ago when she suddenly began to have abdominal pain. Her abdominal
pain was initially intermittent lasting for a few hours at at time. No
clear correlation with food. Yesterday, she noticed that her pain was
much more severe, [**3301-9-5**] in severity and more localized to the right.
This was accompanied by nausea and vomitting. She vomitted twice, with
clear liquid emesis and was sent to [**Hospital3 **].
At [**Hospital1 **], she was noted to have elevated amylase/lipase to 538 and 516
with elevated bili to 4.1 and AST/ALT to 198/115 and was given
ciprofloxacin, flagyl and 500cc NS and was transferred to the [**Hospital1 1**]
emergency department.
.
At [**Hospital1 1**] EDVS 97.9 HR 83 157/92 RR 18 97% RA.
Elderly F, oriented X 2, NAD, flat jvp, CTA decreased b/b, s1 s2
[**Last Name (un) **], decreased BS, + t at
ruq, no edema</topic>
<topic number="21" type="treatment">Mr. [**Known patient lastname 4075**] is a 63 yo man with h/o biphenotypic ALL, now Day + 32
from allogeneic SCT, who presents to clinc with one week of worsening
SOB and two days of a clear productive cough. The patient states his
SOB occured when lying flat, but not with activity. Also admitted to
chest pressure which would come and go in his left chest no related to
the SOB. Sleeps with 3 pillows (no change from baseline), denies PND;
admits to a slight increase in lower extremity edema. Admits to low
grade fevers to the 99's and crampy abdominal pain. Denies chills,
night sweats, vomiting, or diarrhea.
Assessment and Plan
Assesment: This is a 63 year-old male with a history of h/o
biphenotypic ALL, now Day + 32 from allogeneic SCT, who presents with
hypoxia, one week of worsening SOB, and two days of productive cough.
Plan:
# Hypoxia: The patient developed acute onset of hypoxia accompanied by
fever and a one day cough with sputum production. Given that the
patient is about 1 month s/p allogenic SCT the differential is broad
and would include bacterial pneumonia, viral pneumonia (CMV, flu), and
opportunistic infections including fungal infections. Patient also has
a history of CMV infection, aspergillus and Leggionare's disease and is on
posaconazole. His CXR showed an opacification of the left basilar lobe
and also right upper lobe concerning for pneumonia as well as a small
loculated right pleural effusion. Also in the differential is
noninfectious causes such as PE, CHF, or MI. US were negative for clot
and his first set of CE were negative.</topic>
<topic number="22" type="treatment">94 M with CAD s/p 4V-CABG [**3420**] and CRI had been doing well until this
AM when he was out walking with his wife. [**Name (NI) **] abruptly syncopized and a bystander started CPR quickly. The local fire department delivered two shocks without success. Then EMS came and gave two more shocks and he went back into sinus. It is unclear whether he regained
consciousness. He was intubated then brought to [**Hospital1 5**] ED.
.
In the ED, his intial SBP was reported to be 110. Labs show K 2.7 and
Hct 25. He was given 40mEq of KCL. On repeat labs, his K normalized
and his Hct was 33 without any blood. It is unclear whether one of the
labs was erroneous.
the vitals were recorded as: T=34.8, HR 62, 132/74, 18, 100% on AC 18x500, FiO2 100%.
EKG: Sinus at 80 BPM with LAD, prolonged PR, TD 0.5 to 1mm in V4-V6
.
ECHO:
The left atrium and right atrium are normal in cavity size. There is
mild symmetric left ventricular hypertrophy with normal cavity size.
There is mild global left ventricular hypokinesis (LVEF = 45-50 %). The
right ventricular free wall is hypertrophied. Right ventricular chamber
size is normal. with normal free wall contractility. The aortic root is
mildly dilated at the sinus level. The ascending aorta is moderately
dilated. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**1-13**]+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mildly depressed global left ventricular function. Mild to
moderate aortic regurgitation. Mild mitral regurgitation.</topic>
<topic number="23" type="treatment">85y/o m w/ hx AD, diverticulosis, recently dx colon ca
s.p hemicolectomy p/w dark stools and dropping Hct (30
-->26-->23).
NG lavage was negative in ED, however, pt with duodenal ulcer
on EGD [**7-2**]. Possibly recent PUD vs anastomotic site vs [**1-26**] colon ca vs
diverticulosis.
Review of systems:
Constitutional: No(t) Fever
Cardiovascular: No(t) Chest pain, No(t) Palpitations
Respiratory: No(t) Cough, No(t) Dyspnea
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,
No(t) Diarrhea, No(t) Constipation
Since 12 AM
Tmax: 37.3 C (99.2
Tcurrent: 37.3 C (99.2
HR: 69 (64 - 78) bpm
BP: 150/73(91) {128/39(65) - 150/99(103)} mmHg
RR: 16 (16 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
O2 Delivery Device: None
SpO2: 100%
ABG: ////
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal), RRR
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Tender: ,
healing colectomy scar, no erythema, tenderness, bleeding, oozing.
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): only new year and thought he was at [**Hospital1 947**],
Alzheimer's: pt with baseline dementia. Pt oriented to self, but not
time or place.
Movement: Purposeful, Tone: Normal
Labs / Radiology
WBC
9.7
Hct
24.0
Plt
593
Other labs: PT / PTT / INR:14.4/27.2/1.3"</topic>
<topic number="24" type="treatment">This is a 51 year-old M w/ a h/o MS, quadraparesis, HTN, restrictive
lung disease, chronic constipation and SBOs s/p ileostomy, multiple
UTIs (also s/p suprapubic tube) presents with SBO and UTI. Of note he
was just recently discharged from the [**Hospital1 52**] on [**10-2**] for an admission
for a UTI (negative cultures) treated with cipro, shingles treated w/
acyclovir and SBO evaluated by surgery but managed conservatively. He
returns today as his home health aide had noticed his Urine output was
low, 75cc overnight when he usually has about 1 liter of UOP
overnight. His ostomy output has been high. He has not noticed any
symptoms. Over the past two weeks he has had mild earaches, a
sorethroat as well as some rhinorrhea. He has not noticed any watery /
itchy eyes. He has not sure if he has had a change in his ostomy
output or suprapubic output. He has not noticed any visual changes, he
has not noticed any new neurologic si/sx. He denies any abdominal
pain, has not sujectively noticed any change in abdominal distention.
He denies any pain in regards to his zoster (now or when diagnosed).
Denies CP, has an occasional cough that is not worsening.
.
In the ED, he was noted to be severely dehydrated on exam. His BP
nadir was 79/43 and HR peak was 97. T 99 (he usually "runs low"), new
ARF 1.4 up from 0.6.</topic>
<topic number="25" type="treatment">A 64 yo F w/PMHx sx for AF, COPD, HTN, hyperlipidemia who initially had
an open ASD repair c/b sternal wound infection and post-operative AF in
[**11-15**] treated with amiodarone. On [**2-20**], she was initially admitted
through the ED with SOB and back pain, and was noted to have atrial
fibrillation with RVR. A CTA demonstrating diffuse LAD and
post-obstructive PNA concerning for malignancy. For her atrial
fibrillation, she was started on diltiazem gtt, for which she was
transferred to the [**Hospital Unit Name 42**] for monitoring. The atrial fibrillation was
thought to be in the setting of a post-obstructive pneumonia, for which
she was treated with antibiotics. She was then transferred to the floor
later that same night on metoprolol 50 mg tid. While on the floor, she
had a bronchoscopy performed which showed external compression of her
left mainstem bronchus, and she had a biopsy/FNA performed, which
showed large cell carcinoma. She was then readmitted to the [**Hospital Unit Name 42**]
yesterday with atrial fibrillation with HR 130s, and was started on a
diltiazem gtt.
.
In the [**Hospital Unit Name 42**], she was started on po diltiazem, which was rapidly
uptitrated to 60 mg qid. She was called out this morning. Tonight, at
8:30 pm, she was noted to have HR 160s, w/EKG c/w AF with RVR, for
which she received metoprolol 5 mg IV x2, followed by diltiazem 10 mg
IV x2 without conversion. She denies chest pain, SOB, tachypnea. She
does note some diaphoresis and occasional palpitations.</topic>
<topic number="26" type="treatment">Briefly 79 yo F w/ a h/o CAD s/p RCA stenting BMS to mRCA [**3421**] and pLAD
[**3423**], diastolic CHF (2 pillow orthopnea), 1+ MR, HTN, Hyperlipidemia,
previous smoking history, and atrial fibrillation initially p/w cough,
dyspnea.
.
Briefly, pt's symptoms began [**Month (only) 760**]. At that time pt was admitted
with GI bleed, transfused and discharged without resolution of
symptoms. Furthur workup noted bilateral atrial thrombi and
anticoagulation was reinitiated. CTA did not show PE but was concern
for small peripheral emboli as cause of dyspnea. Pt was had multiple
PFTs, echos, CT scans and CXRs without definitive cause of dyspnea.
Most recent PFTs on [**3432-12-27**] c/w restrictive ventilatory defect and low
DLCO suspicious for interstitial pulmonary process (worsening). She has
been followed by cardiology and pulmonology and is being treated for
dCHF and reactive airway disease.
.
On current admission pt presented with cough, thought to be URI, rather
than worsening of chronic dyspnea. Current etiology considerations
include CHF vs intrinsic pulmonary disease (infiltrative) vs embolic
disease.
In order to optimize cardic function with atrial kick, pt was
pretreated with Sotolol and underwent TEE and cardioversion of afib on
[**3433-1-11**]. After cardioversion, patient developed junctional HR to 45bpm
with SBPs in 80s. She was placed on dobutamine and HR increased to 80s
(sinus vs antrial escape rhythm). Off of dobutamine, HR and BP
decreased with EKG demonstrated QTc of 700.</topic>
<topic number="27" type="treatment">96F found unresponsive on ground at nursing home. Pt was
in dining room and found by staff. Unresponsive for 1 min after
found. Pt cannot recollect events preceding fall but with some
c/o HA and some neck/shoulder discomfort. Taken to [**Hospital1 1218**]
where NCHCT preformed at 18:32 showed ~9mm L parietal SDH.
C-spine negative.
Family / Social history:
dementia, HTN, afib, CAD
SURGICAL Hx: unknown
.
SOCIAL Hx: Daughter serves as HCP; Pt currently DNR/DNI except for
elective procedure (****SEE CLARIFICATIOIN BELOW****).
.
ALLERGIES: NKDA
Physical Examination
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:
Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear :
bialterally)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Verbal
stimuli, Oriented (to): A+O x 2, Movement: Not assessed, Tone: Not
assessed
Imaging: CT head w/o contrast Acute left subdural hematoma measuring
1.5 cm maximal dimensions with leftward subfalcine herniation of 8 mm,
downward transtentorial herniation with obliteration of the left
suprasellar cistern, and uncal herniation. No fx, destructive
infiltrative lesion involving the skull base</topic>
<topic number="28" type="treatment">84 year-old man with CAD s/p CABG, DM, HTN, presented with 2 days of
black stools and coffee ground emesis. Pt reports of woke up 2am on
[**10-19**] and had black soft/loose BM, followed by nausea and and vomiting
blackish liquid. He felt better but continued to have three more black
stools over the next two days. He vomited a total of [**1-20**] times before
presenting to the hospital. He has been feeling lethargic and
lightheaded and called the ambulence at the advice of his son. His
stools were lightening in color prior arriving. He has not been using
any new medications and has not had a prior GIB.
.
In the ED, initial VS: 98.7 88 65/47 98%/RA. He was BIBEMS with SBPs
110-120s and has had similarly stable blood pressures since arrival.
He had an NG lavage with coffee ground emesis that cleared with 600 cc
of flushing. During the lavage he had chest pressure and an EKG showed
STD in V2-4. He did not have radiation, pain, or diaphoresis.
Home medications:
ALLOPURINOL 300 mg Tablet by mouth daily
GLIPIZIDE 5 mg Extended Rel by mouth daily
LOSARTAN [COZAAR] 100 mg by mouth daily
METFORMIN 500 mg by mouth daily
METOPROLOL TARTRATE 50 mg by mouth daily
PIOGLITAZONE [ACTOS] 15 mg by mouth daily
SIMVASTATIN 80 mg Tablet by mouth daily
ASPIRIN 81 mg Tablet by mouth daily
Past medical history:
Coronary artery disease s/p triple-vessel coronary artery bypass in [**7-/2899**]
Hypertension
Peripheral arterial disease
Hypercholesterolemia
Diabetes
Osteoarthritis
Gout
Anemia Baseline 32-35 with unrevealing w/u by heme
Right hernia repair in [**2877**]
Appendectomy in [**2841**]
Prostate disease
N/C
Occupation: Retired trial lawyer
Drugs: Denies
Tobacco: Denies
Alcohol: Occasional</topic>
<topic number="29" type="treatment">54 y/o M w/IPF, called today with worsening dyspnea x 3 days. He had
been in unusal state of health at baseline resp status (using 4L NC at
rest and 6L NC with exertion) when 3 days PTA, he hugged his cousin who
has rats for pets and also the heat came up from the basement of his
house. He feels that with these two events, he breathing became acutely
worse and is concerned for allergen exposure. He denies any sick
contacts, fevers, chills, worsening [** 2169**]/productive [** 2169**], rhinorrhea.
He did receive flu and pneumovax.
.
He has had a recent admissions in [**11-26**] with progressive DOE. CT
revealed increased ground glass opacity in LL superimposed on pulmonary
fibrosis with elevated eosinophils peripherally (12%). A BAL was also
positive for eosinophils. He was started on high dose steroids
(prednisone 60mg) [**2739-2-16**] with plan for close outpatient follow up for
eosinophilic lung disease. He was discharged on [**2-20**] on 2-3L NC. He then
represented to [**Hospital1 1**] on [**12-12**] for spontaneous pneumomediastinum of
unclear etiology.
.
On day of admission, Pt called pulmonologist (Dr. [**First Name (STitle) **] c/o worsening
shortness of breath since Saturday [**3-23**]. Yesterday he was at pulmonary
rehab and desaturated to the 70s on 6L with minimal exertion, and he is
currently on 4L NC at rest. No sick
contacts recently and [**Name2 (NI) 2169**] has not changed. He was asked to go to ED
given concern for either acute exacerbation of underlying IPF vs
superimposed infection vs pneumothorax.
.
In the ED, initial vs were: 98.3, 96, 144/97, 24, 97% 6L NC.</topic>
<topic number="30" type="treatment">85 y/o F with PMHx of HTN, HL, h/o breast CA and 3cm renal pelvis
transitional cell tumor who presented for nephrectomy on [**2575-8-15**]. Her
post op course was complicated by agitation thought due to narcotics.
Today, she was restarted on her home meds and while on telemetry, pt
was noted to be bradycardic to 40s. Pt was triggered for SBP of 70 and
HR of 40 during which she remained asymptomatic. She was given 1L IVF
and her HR/BP trended back up to baseline. However, there was a second
event an hour later when she sat up and became bradycardic in the 30s
with associated hypotension. Second episode occurred with position change
and again, pt developped junctional rhythm in 30s.
home meds:
Verapamil 240mg daily
Lisinopril 5mg
Rosuvastatin 10mg
Meclizine 25 TID PRN
Imipramine 25 QHS
Colace 100mg
Loratidine 10mg daily
Physical Examination
T: 98 BP: 111/47 P: 74 R: 16 O2: 98% on 2L NC
General: oriented to person only, NAD, comfortable
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, unable to appreciate JVP due to habitus
Lungs: poor effort but [**Month (only) 199**] BS at bases and some audible airway
secretion in upper airways
CV: Regular rate and rhythm, no m/r/g, diff to auscult [**2-13**] habitus
Abdomen: diffusely tender, bowel sounds present, multiple surgical
incisions, clean dry and intact, abd binder in place
GU: foley in place
Ext: cool, no edema, 1+ pulses, pneumoboots in place</topic>
</topics>
Datasets
Models
