notable for her diffuse expiratory wheezes and scattered expiratory crackles .

scattered expiratory crackles
her diffuse expiratory wheezes


no acute pathology was noted and no treatment was necessary at this time .


the electrocardiogram showed a short pr interval with no delta wave , clockwise rotation present .

clockwise rotation present
a short pr interval
delta wave


urinalysis was normal .


notable for a history of trigeminal neuralgia , left shoulder surgery , fibrocystic breast disease , endometriosis and status post total abdominal hysterectomy .

trigeminal neuralgia
total abdominal hysterectomy
fibrocystic breast disease
endometriosis


a left and right heart catheterization and coronary angiogram revealed aortic 120/70 , mean 95 , pa 26/10 , mean 17 , pc 7 , rv 26/6 , ra 4 , cardiac output 5.7 , index 3.8 .

a left and right heart catheterization
mean
cardiac output
index
pc
ra
coronary angiogram
pa
rv
aortic
mean


urine cotenine level none detected .


the lh was 4.9 , fsh 3.3 .


bun 12 , creatinine 0.6 , glucose 92 , uric acid 3.3. cholesterol 236 , triglycerides 115 , hdl 99 , ldl 114 , total protein 6.2 , globulin 2.6 , direct bilirubin 0 , total bilirubin 0.2 , alkaline phosphatase 59 , amylase 64 , sgot 16 , ldh 141 , cpk 57 .

uric acid
cholesterol
creatinine
alkaline phosphatase
cpk
direct bilirubin
triglycerides
glucose
bun
total protein
total bilirubin
amylase
hdl
ldl
sgot 16
globulin
ldh 141


she was noted to have mild cataracts , possibly due to chronic steroids , as well as a subtle temporal disc pallor od , possibly due to previous episode of optic neuritis .

mild cataracts
a subtle temporal disc pallor od
optic neuritis


estradialol pending .


she has no history of asbestos exposure or tuberculosis exposure .


tsh was 124 , cortisol 2.1 , 25 hydroxy vitamin d , and 125 dihydroxy vitamin d levels were pending .


mrs. cast is a 50 year old white female with a history of chronic obstructive pulmonary disease and evidence of severe lobular emphysema , who has progressive shortness of breath and inability to carry on with activities of daily living without assistance .

severe lobular emphysema
chronic obstructive pulmonary disease
progressive shortness of breath


varicella antibody positive , cmv antibody positive , toxo negative , rpr non reactive .

cmv antibody
varicella antibody
toxo
rpr


sed rate 6 .


pt 9.5/10.0 , ptt 23.9 .


hiv testing results pending .


systemic arterial resistance 12/81 .


dr. koteelks indicated that the patient did not have sinus problems currently but thought that the trigeminal pain might be investigated further and that the sphenoid might account for some of the patient 's discomfort .

the trigeminal pain
the patient 's discomfort
sinus problems
the sphenoid


dr. tikkerth felt that the patient had mild adjustment related anxiety under good control with a history of tobacco abuse in the past .


fev1 0.78 liters , vital capacity 2.12 liters , total lung capacity 5.51 liters , single breath dlco 5.3 ( 25% predicted ) .

vital capacity
fev1
total lung capacity
single breath dlco


chronic obstructive pulmonary disease


she knows to return to her local physician for her routine care with her condition unchanged at the time of discharge .


hepatitis serologies pending .


abdominal ultrasound was unremarkable .


the patient completed the studies and to be informed of the results as an outpatient .


the patient has been steroid dependent for two years and has been intubated in the past only once for a surgical repair of trigeminal neuralgia .


magnesium 1.7 .


steroid complications , including cataract , osteoporosis , diffuse fibrocystic breast disease , trigeminal neuralgia .

cataract
diffuse fibrocystic breast disease
trigeminal neuralgia
osteoporosis
steroid complications


the breasts were notable for fibrocystic changes .


cranial nerves were intact except for paresthesias on the left in the vii and viii distribution .


echocardiogram showed normal right ventricular and left ventricular size and systolic function .


cardiopulmonary exercise study results are pending .


she was admitted to the hospital for a pre lung transplant evaluation .


chest pain / sob


r lung mass , likely cancer


vicodin 1-2 tabs po q6h prn pain , # 50 , no refills


physical examination , laboratory evaluation , cxr , chest ct

laboratory evaluation
chest ct
cxr
physical examination


we are scheduling you for a needle biopsy by interventional radiology for some time in the next week .


significant for left tm scarring without acute inflammation or drainage .

left tm scarring
drainage
acute inflammation


she has had no fevers , chills , respiratory symptoms , diarrhea , bright red blood per rectum or melena .

chills
melena
bright red blood per rectum
fevers
respiratory symptoms
diarrhea


no anorexia .


the patient has had no symptoms until approximately two years ago when she began having classic biliary colic pain with right upper quadrant epigastric pain radiating to midback with nausea , but without vomiting .

nausea
symptoms
right upper quadrant epigastric pain
classic biliary colic pain
vomiting


significant for a left ear operation approximately 30 years ago with left tm reconstruction in december 1999 at hitch hospital .

left tm reconstruction
a left ear operation


only multivitamins .


no lymphadenopathy is noted .


abdomen is soft and nontender without hepatosplenomegaly or mass .


episodes have been increasing in frequency over the last few months .


the patient was admitted to the hospital on july 12th for a chole with a principle diagnosis of recurrent biliary colic .


the patient was admitted for the lap coli with an intraoperative cholangiogram by dr. sterp under general anesthesia .


she has no family history of gallbladder or pancreatic disease .


cardiac exam ; she has positive s1 , s2 without murmur , rub or gallop .


rate was 75 .


she has had no significant weight loss .


she has had ultrasound proven gallstones for ten years , seen on an earlier obstetric ultrasound .


the patient is a healthy appearing female looking her stated age in no apparent distress .


she has not found any relieve with any over the counter medications .


the patient is a 42 year old with recurrent biliary colic .


she is anicteric without rash or heent .


her rectal exam is guaiac negative .


she has no history of liver disease , hepatitis .


she has no rebound or guarding .


an ultrasound on 1/25/00 showed six gallstones without cholecystitis .


the patient was afebrile , vital signs were stable .


she is without bruits or jvd .


percocet 5 mg in 325 mg one to two tabs po q4 to 6 prn pain .


no known drug allergies


lungs are bilaterally clear to auscultation .


operative course and recovery were without complication .


dermoplast topical tp q12h prn pain docusate sodium 100 mg po bid prn constipation ibuprofen 400-600 mg po q6h prn pain

dermoplast topical
ibuprofen
docusate sodium


nka


take with food prenatal multivitamins ( stuartnatal 1+1 ) 1 tab po qd tucks ( witch hazel ) topical tp q4h prn pain


labor at term


no observed abnormalities


initial newborn exam :


abdomen obese , no scars .


total abdominal hysterectomy , bilateral salpingo oophorectomy 2-19-91 by dr. lako coma .

bilateral salpingo oophorectomy
total abdominal hysterectomy


accordingly she presents for operative therapy at this time .


she had a normal abdominal exploration of a small uterus with superficial invasion on gross examination , normal ovaries .

a normal abdominal exploration
gross examination


endometrial cancer .


pelvic exam showed a small mobile uterus .


a subfascial j-p was left .


the patient 's postoperative hct was 34 .


the patient was brought to the operating room on 2-19-91 where she had an exploratory laparotomy , tah / bso , and omental biopsy .

omental biopsy
an exploratory laparotomy


this is an 81-year-old who presented with postmenopausal spotting and had an endometrial biopsy which was read at the etearal etsystems/ hospital as showing grade i adenocarcinoma .

grade i adenocarcinoma
postmenopausal spotting


extremities show no edema .


washings were sent .


subfascia drain was discontinued .


on standing , she tended to fall to the front , back or sides without trying to stop her fall initially , and extensive gait testing was deferred due to concerns for safety .


coordination - toe tap was slow bilaterally , although difficult to reproduce , and at best , was essentially within normal limits .


her lungs were clear to auscultation bilaterally .


the patient was admitted for her gait disorder with other notable findings on examination including anisocoria , which , by the patient 's report , had been noted several months earlier .

her gait disorder
anisocoria
notable findings


on the second hospital day , her gait continued to be markedly unstable , although with no consistent pattern in terms of weakness or directionality of falling , and she continued to have no reproducible upper extremity or lower extremity ataxia or dysmetria .


she had been placed on heparin initially , but this was discontinued after the magnetic resonance imaging results were obtained .


the psychiatrist also noted the indifference the patient evinced regarding her own symptomatology .


in the subsequent two days , she had several small spells of " imbalance " , particularly towards the right , and other symptoms included diffuse and mainly frontal headaches and mild neck soreness .

other symptoms
diffuse and mainly frontal headaches
mild neck soreness
small spells of " imbalance


her doxepin has recently been increased .


a magnetic resonance imaging and magnetic resonance angiogram study was obtained , which showed no clear evidence of arterial dissections or infarction or other pathologic processes .

infarction
other pathologic processes
arterial dissections

magnetic resonance angiogram study
a magnetic resonance imaging


her extremities were without clubbing , cyanosis , edema , or rash ; there were some older hematomas in the bilaterally shins .

hematomas in the bilaterally shins
clubbing
cyanosis
edema
rash


there was no diplopia , visual loss , speech abnormality or sensory change in her history .

diplopia
speech abnormality
sensory change
visual loss


her erythrocyte sedimentation rate was 12 .


her heel-to-shin and finger-to-nose testing was fully intact bilaterally without ataxia or tremor .


she had slightly slow fine finger motility approximately equal bilaterally , although this was extremely difficult to reproduce .


she was not felt to be acutely suicidal or otherwise in need of acute psychiatric treatment .


motor examination revealed 5/5 power in all groups in the proximal and distal upper and lower extremities .


she was in her usual state of health until 3/20/97 when she experienced the fairly sudden onset of predominantly right-sided arm and leg weakness and ataxia .


her coagulation parameters were normal .


there were no carotid or cervical bruits .


the patient was evaluated in one of the neurology conferences for several hours , and during this time , showed significant improvement while receiving gait training as well as evaluation ; in particular , she became more stable with counter-balancing methods .


there was no nystagmus and no ptosis .


she was pleasant , in no acute distress ; blood pressure 130/60 ; heart rate 66 ; respirations 18 ; temperature 98 .

temperature
blood pressure
respirations
heart rate


the patient is a 31-year-old right-handed female with right-sided greater than left-sided weakness and difficulty walking for several days .


is notable for depression , and she has been followed regularly by dr. freiermchird of nash health for several months with pharmacologic treatment , which is apparently working well .


gait disorder .


were unremarkable with normal electrolytes and complete blood count parameters .

complete blood count parameters
electrolytes


reflexes were 2+ throughout in the upper and lower extremities , and toes were downgoing .


her affect was slightly inappropriate at times ; for example , singing or humming along while performing some of the motor tasks and giving the impression of indifference to the deficits that were demonstrated on the examination .

singing or humming along
slightly inappropriate
the deficits
indifference


she was seen by the psychiatry service .


head ct scan without contrast showed normal brain parenchyma and no intracranial process .


posterior transcranial doppler studies showed normal studies of both vertebral arteries , and carotid non-invasive studies showed normal right and left carotid bifurcations .

carotid non-invasive studies
posterior transcranial doppler studies


she evidently recovered from the episode after a number of minutes .


quinine gives her a rash .


there was no drift .


there was no jaw jerk and no hoffman 's sign .


she will continue on her previous outpatient medical regimen .


the only medications she is on are paxil 30 mg p.o. q.day , doxepin 25 mg p.o. q.day , and klonopin 2 mg p.o. q.h.s.


she had a normal s1 and s2 and regular rate and rhythm with no murmurs .


she is status post appendectomy and otherwise has no remarkable past medical history .


the following day , she remained in bed through essentially all of the day due to malaise with no specific deficits being noted .


ct scan shows ovarian cyst


vicodin


abd pain/ pelvic pain


if you have continued fevers , worsening abdominal pain , discharge or other worrisome symptoms , please return to the emergency department .

worsening abdominal pain
other worrisome symptoms
discharge
fevers


abdominal pain treatment rendered :


the patient was given printed instructions for abdominal pain ( english ) .


following evaluation and treatment , the patient 's disposition at the end of the visit was admitted as an inpatient to fairm of ijordcompmac hospital .


the patient presented with a chief complaint of sdh .


the patient 's preliminary admitting physician is glyncred , nabeth n and the preliminary diagnosis is sdh .


iv abx


colace ( docusate sodium ) 100 mg po bid ibuprofen 600 mg po q6h prn pain aldomet ( methyldopa ) 250 mg po bid percocet 1-2 tab po q4h prn pain

colace ( docusate sodium )
ibuprofen
aldomet ( methyldopa )
percocet


no heavy lifting ; nothing in the vagina for 6 weeks -- no intercourse , no douching , no tampons ; call for fever above 100.5 , worsening abdominal pain , heavy bleeding , or any other concern ; no driving while taking percocet

heavy bleeding
worsening abdominal pain
any other concern
fever above 100.5


12/02/03 03:20 pm apgars 7,8


your obstetrician 6 weeks , no known allergies


attending evaluation


principal discharge diagnosis ; responsible after study for causing admission ) s / p cesarean


epidural vaginal delivery :


no observed abnormalities


s / p cesarean


other diagnosis ; conditions , infections , complications , affecting treatment / stay s / p cesarean


non-reassuring fetal status , uterine


, other - bradycardia


weight :


post dates


please use ice to sore areas for the next few days .


xray - no evidence of fracture


motrin 600 mg every 8 hours for pain - please take with food in your stomach


s / p motor vehicle accident , muscle contusions


the patient was given printed instructions for sprains , fractures and bruises ( english ) .


the patient was given printed instructions for motor vehicle accident - trauma ( english ) .


if you develop trouble breathing , worsening pain , vomiting or any other concerns please return to the ed for further evaluation .

worsening pain
any other concerns
trouble breathing
vomiting


the patient walked with her feet externally rotated with a wide based gait with shuffling short steps with a tendency to fall back and she was unable to walk without assist .

a tendency to fall back
a wide based gait
shuffling short steps
her feet externally rotated


csf tube labeled # 4 was notable for csf color pink , csf turbidity slight , csf xanthochromia yes , csf rbcs 3,900 , csf white blood cells 3 , csf neutrophils 61 , csf bands 3 , csf lymphs 31 , csf monos 1 , csf eos 3 , csf basos 1 .

csf monos
csf neutrophils
csf eos
csf basos
csf white blood cells
csf bands
csf turbidity
csf rbcs
csf xanthochromia
csf lymphs
csf color
csf tube labeled # 4


this is a 44 year-old right handed woman with down 's syndrome who presents with increased falling and gait unsteadiness and an increased inability to perform her activities of daily living over the past three years .

increased falling
down 's syndrome
gait unsteadiness
an increased inability


tube and requisition of the csf labeled tube # 1 was notable for color pink , turbidity slight , xanthochromia yes , red blood cells 3,800 , white blood cells 3 , neutrophils 58 , bands 4 , lymphs 29 , monos 6 , eos 2 and basos 1 .

neutrophils
white blood cells
eos
red blood cells
bands
color
turbidity
lymphs
xanthochromia
csf labeled tube # 1
monos
basos


abdominal examination was soft , non-tender , positive bowel sounds .


her mental status remained similarly to her admission examination .


notable for decreased ability to do her activities of daily living , a decrease in her language , some urinary accidents , increased falls and a poor gait .

some urinary accidents
a decrease in her language
a poor gait
increased falls
decreased ability


notable for down 's syndrome , altzheimer 's disease secondary to down 's syndrome diagnosed in 1998 , status post multiple falls , no heart disease , ankle surgery and an abnormal eeg .

heart disease
altzheimer 's disease
down 's syndrome
down 's syndrome
an abnormal eeg
multiple falls


opening pressure was 17 and approximately 20-25 cc of csf was removed .


reflexes were 2+ bilaterally with down going toes .


because of poor compliance with the gait examination it was very difficult to assess changing gait post lumbar puncture .


on hospital day the patient underwent conscious sedation in the operating room where lumbar puncture was performed .


the fluid culture was no growth to date .


include lamictal 50 mgs bid , aricept 10 mgs qhs , buspar 15 mgs bid , trazodone 100 mgs qhs .


the patient had back folliculitis .


the patient 's neuro examination was largely unchanged from the admission neuro examination .

the patient 's neuro examination
the admission neuro examination


on the night of admission lumbar puncture was attempted on the floor , but we were unable to get cerebral spinal fluid due to difficulty with compliance with the patient who was severely agitated and would not comply with the examination .


heent examination is notable for bilateral esotropia .


chest was clear to auscultation .


csf gram stain was notable for no polys and no organisms seen .


noted for friendly , jovial 44 year-old woman with down 's .


csf was notable for sugar level of 65 and total protein level of 56 .


cardiac examination was regular rate and rhythm .


there are no known drug allergies .


one day prior to lumbar puncture , an aerobic culture was similarly pending .


lyme capture was pending and at the time of discharge .


the patient had an mri at an outside hospital which showed enlarged lateral ventricles and the possible diagnosis of normal pressure hydrocephalus was entertained and the patient was admitted for diagnostic lumbar puncture .

enlarged lateral ventricles
normal pressure hydrocephalus


the diagnosis of alzheimer 's was made in 1998 .


cranial nerves notable for bilateral esotropia .


blood pressure 150/82 , heart rate 88 , respiratory rate 18 .

blood pressure
respiratory rate
heart rate


this is a 44 year-old right handed woman with down 's syndrome who presents with falling and a decrease in her activities of daily living .

down 's syndrome
falling
a decrease in her activities


vitamin b12 of 855 , folic acid of 15.4 .


rpr card test was negative .


mri , as discussed , was done at outside hospital and demonstrated large ventricles .


left ankle was notable for swelling secondary to status post left ankle surgery .


the patient was admitted to the arkzie- memorial for lumbar puncture .


chem-7 was within normal limits .


neuro examination was notable for a patient who was alert and oriented x 1 .


alzheimer 's disease secondary to down 's syndrome .


pregnancy , term


docusate sodium 100 mg po bid prn constipation ibuprofen 400-600 mg po q6h prn pain


perineal , 1st degree


take with food prenatal multivitamins ( stuartnatal ) 1 tab po qd maalox-tablets quick dissolve / chewable 1-2 tab po q6h prn upset stomach


cnm evaluation


no observed abnormalities


repair of first degree perineal laceration


weight :


laceration :


apgars 9,9


he was flaccid bilaterally .


consent for autopsy was denied .


3. residual of previous right middle cerebral artery stroke .


he remained unresponsive with poor airway protection .


he was at orlak on the day of admission and was found unresponsive with left tonic-clonic movements , greater in the arms than in the legs .

unresponsive
left tonic-clonic movements


the right upper extremity was flaccid and paresthetic .


he had stertorous breathing , positional tremors of the left upper extremity , a spastic left hemiparesis in flexion .


at 1:15 pm on 10/06/94 , the patient was found unresponsive with no heart sounds , carotid pulse , respiratory excursions , or pupillary reactions .

carotid pulse
unresponsive
heart sounds
respiratory excursions
pupillary reactions


he was transferred to fairm of ijordcompmac hospital , where seizures were stopped with 2 mg of ativan .


he had no carotid bruits .


he was loaded with iv dilantin .


he had no oculocephalic reflexes .


this 85 year old man was admitted because of the new onset of focal left-sided seizure and unresponsiveness .

unresponsiveness
focal left-sided seizure


he had a past history of ischemic cardiomyopathy with an ejection fraction of 10 , mild aortic stenosis and a right middle cerebral artery territory stroke in 07/94 .


after one hour his eyes were midline and he remained unresponsive .


he withdrew both legs to painful stimuli .


an electroencephalogram revealed generalized slowing without ictal events .


1. left middle cerebral artery territory cerebral infarction .


2. cardiomyopathy .


routine post partum care


active labor


height 49 heent normal mouth normal neck normal breasts normal nipples normal chest normal cor normal abdomen normal gravid , + fhr , nt extrem normal skin normal nodes normal vulva normal vagina normal cervix normal 4-5/100% os normal closed , firm , -cmt adnexae normal uterus normal term 7-7.5 # vtx uterine size in weeks normal term


vacuum extraction


active labor .


abnormal pap test , history of


she delivered a 3263 gram female infant at 06/14/2001 at 06:40 pm with apgar scores of 8 and 8 at one and five minutes respectively at 40.3 weeks gestation via vacuum extraction .


abnormal fetal heart rate / rhythm - delivered


fetal bradycardia .


nuchal cord , times two .


the patient presents now for right modified radical mastectomy with impant .

impant
right modified radical mastectomy


this is an 81 year old female with a right breast mass with a discharge .


in the fall of 1991 , nipple changes and discomfort was again noted .


on the left , there was a new shawdown but the biopsy was negative .


two drains were used .


discharge medications include percocet and colace .


clear lungs , normal heart , pagett 's type changes on the right breast and left breast without apparent masses with scarring supra-areolar and infra-areolar .


one drain was removed on postoperative day number two , and the second drain she will be discharged to home with .


a mammogram of the right breast with shadow biopsy was negative .

a mammogram of the right breast
shadow biopsy


a biopsy scar on the right breast from 1990 .


subsequently a saline-filled right breast implant was performed .


the patient was taken to the operting room on 8/7/92 , where a right modified radical mastectomy was performed .


a mmamogram showed no change on right , but new biopsy was positive .


no known drug allergies .


the patient tolerated the procedure extremely well .


the patient will be followed at rehabilitation by her primary care physician , dr. both .


the patient was evaluated by the surgical service who felt that the wound was clean with some erythema but without evidence of true cellulitis .


a neurological examination was performed which revealed no abnormality and imaging included a head scan which revealed no bleed and a cervical spine series which revealed degenerative joint disease but no obvious fracture .

abnormality
degenerative joint disease
obvious fracture
bleed

a neurological examination
a cervical spine series
imaging
a head scan


11) axid 150 mg p.o. b.i.d.


7) history of colitis .


1) aortic stenosis , severe , echocardiogram in july of 1998 with a peak gradient of 6-8 mm of mercury , aortic valve area calculated to be 0.5 cm squared by the continuity equation .

aortic valve area
echocardiogram
continuity equation
a peak gradient


there was no s3 appreciated .


sodium was 142 , potassium 3.3 , chloride 99 , bun 23 , creatinine 1.1 .

creatinine bun sodium chloride potassium


the patient 's coumadin was continued .


the patient has a history of severe aortic stenosis and was recently admitted to the retelk county medical center for a nafcillin sensitive staphylococcus aureus cellulitis of the right leg treated with a course of nafcillin and levofloxacin .


13) zyrtec 10 mg p.o. q. day .


a neurologic work-up was undertaken which included a ct scan of the head which revealed no acute bleed and a lumbar puncture which revealed a glucose of 72 , protein 65 , white blood cell count 19 , red blood cell count 11,500 with no evidence of xanthrochromasia .

a neurologic work-up
a glucose
protein
red blood cell count
a ct scan of the head
white blood cell count
a lumbar puncture


hematocrit was 33.0 , platelet count 627 , white blood cell count 10,000 , mcv 79.8 .

mcv
white blood cell count
platelet count
hematocrit


the patient has a history of critical aortic stenosis and mitral regurgitation .

mitral regurgitation
critical aortic stenosis


calculated ejection fraction was 45-50% .


vascular examination was notable for 1+ carotid impulses which were diminished and delayed and the above mentioned transmitted cardiac murmurs .

1+ carotid impulses
transmitted cardiac murmurs


mental status changes .


a head ct scan and cervical spine series were negative .


mental status change , cellulitis


urinalysis revealed trace microscopic hematuria with 47 red blood cells per high powered field , 1+ bacteria .


heart rate 60 , respiratory rate 18 , blood pressure 116/80 , temperature 97.1 degrees , oxygen saturation 93% on room air .

temperature
respiratory rate
blood pressure
oxygen saturation
heart rate


head ct scan performed in the emergency department revealed no bleed .


ast was 25 , alkaline phosphatase 130 , total bilirubin 3.2 , albumin 3.4 , calcium 8.8 .

albumin
alkaline phosphatase
calcium
ast
total bilirubin


digoxin level was 0.8 .


6) abnormal liver function tests :


the patient is an 88 year-old woman undergoing treatment for a right lower extremity cellulitis who was transferred from child for worsening cellulitis and new confusion .

a right lower extremity cellulitis
worsening cellulitis
new confusion


neurological examination revealed that the patient was quite sedated at this time having received some medications .


the heart examination revealed that the patient had a sustained pmi which was located in the left mid clavicular line , s1 , near complete obliteration of the second heart sound by a two out of six high pitched murmur peaking at mid to late systole and heard across the precordium .


5) atrial fibrillation :


10) buspar 5 mg p.o. t.i.d.


1) aspirin 81 mg p.o. q. day .


12) buspar 5 mg p.o. t.i.d.


the patient has a history of congestive heart failure .


she was arousable only to painful stimuli .


coagulation studies revealed a pt of 17.4 seconds with an inr of 2.1 , ptt 25.5 .


the patient 's extremity examination was notable for erythema of the right calf with a small ulcer with a relatively clean base .

a small ulcer
erythema of the right calf


abdominal examination revealed that the abdomen was soft , non-tender , non-distended , no organomegaly , no masses , normal active bowel sounds .

masses non-tender non-distended organomegaly


skin examination was notable for a leg ulcer and cellulitis to be delineated below .


head and neck examination was benign .


7) potassium 20 meq p.o. q. day .


neck was supple with no thyromegaly .


the neurology service evaluated the patient who felt that her agitation was most likely due to infection , her multiple medications , or her metabolic condition .

her agitation
infection
her metabolic condition


physical examination on admission revealed an elderly woman , sleeping , responsive only to noxious stimuli after having received some sedation in the emergency department .


4) history of transient ischemic attack / cerebrovascular accident .

cerebrovascular accident
transient ischemic attack


2) mitral regurgitation , 2+ on july of 1998 echocardiogram .


3) status post fall .


9) amitriptyline 10 mg p.o. q.h.s.


the patient 's antibiotics were discontinued with the thought that prolonged antibiotics only put her at more risk for infection .


10) levofloxacin 250 mg p.o. q. day .


1) digoxin 0.125 mg p.o. q. day .


the patient decided not to pursue further testing with a neck ct scan .


she had also been noted to be confused and combative during that 24 hour period .


4) zaroxolyn 0.25 mg p.o. q. day .


2) digoxin 0.125 mg p.o. q. am .


lungs were clear to auscultation bilaterally .


3) lasix 40 mg p.o. b.i.d.


these liver function tests will be followed closely as an outpatient .


2) mitral regurgitation .


1) aortic stenosis .


2) lasix 80 mg p.o. b.i.d.


7) kay ciel 20 meq p.o. q. day .


on admission , the patient was noted to have elevated bilirubins in the 3 range and mildly elevated alkaline phosphatase consistent with a cholestatic picture .

cholestatic picture
mildly elevated alkaline phosphatase
elevated bilirubins


9) fosamax 10 mg p.o. q. day .


5) right lower extremity wound .


on admission to the emergency room , the patient was somewhat argumentative and confused as well as uncooperative with procedures .

argumentative
uncooperative with procedures
confused


8) history of vertebral body fractures .


4) status post fall :


5) zaroxolyn 2.5 mg p.o. q. day .


3) aspirin 81 mg p.o. q. day .


4) history of cerebrovascular disease .


3) history of atrial fibrillation .


2) right lower extremity cellulitis :


8) fosamax 10 mg p.o. q. day .


4) coumadin 2 mg p.o. q.h.s.


there was also a blowing holosystolic murmur heard at the patient 's apex to axilla .


there was also a right leg fluid collection that was incised and drained on august 1 , 1998 .


6) coumadin 2 mg p.o. q.h.s.


the patient was sent to rehabilitation on levofloxacin orally .


6) history of temporal arteritis on chronic steroids .


the patient 's admission chest x-ray revealed no infiltrate , no congestive heart failure .


5) hypertension .


there were no spider angiomata .


the patient appeared to have no deficits at the time of discharge .


6) atrial fibrillation .


5) prednisone 5 mg p.o. q.o.d.


she was able to move all four of her extremities in response to pain .


vital signs :


the patient had no known drug allergies .


although details were not available at the time of admission , apparently , she had done well until the 24 hours proceeding admission when the cellulitis was felt to be worsening .


8) prednisone 5 mg p.o. q.o.d.


6) toprol xl 50 mg p.o. q. day .


her deep tendon reflexes were slightly diminished at 1+ bilaterally , but symmetric .


following triage , the patient left without treatment .


the patient presented with a chief complaint of r thumb injury .


ast 29 , alk 151 , total bilirubin 0.2 , total protein 7.2 , albumin 4.3 , globulins 2.9 , calcium 8.9 .

total protein
total bilirubin
ast
calcium
globulins
alk
albumin


the patient is a 68 year old with acute leukemia .


the abdomen was soft , nontender and nondistended with no guarding and no hepatosplenomegaly .

nondistended hepatosplenomegaly guarding nontender


the patient began to experience urinary retention and was straight catheterized .


an abdominal mri was performed to assess continued elevated liver enzymes ; however , the mri was negative .


15) peridex 30 cc p.o. b.i.d. x 14 days .


no chest pain .


sodium 138 , potassium 4.2 , chloride 98 , bun 21 , creatinine 0.7 , glucose 117 , white blood cell count 13,200 , hematocrit 22.5 , platelet count 40,000 .

sodium
chloride
creatinine
potassium
hematocrit
glucose
platelet count
bun
white blood cell count


some shortness of breath with allergies , particularly cats .


11) simethicone 80 mg p.o. q.i.d. p.r.n. gas pain .


the patient 's allergies include a questionable penicillin reaction ; however , the patient tolerated ampicillin well .

penicillin reaction
the patient 's allergies


the patient 's past medical history is significant for allergies , depression and anxiety , pleural thickening / asbestosis , chronic left bundle branch block , tonsillectomy , adenoidectomy , vein stripping ( 1968 ) , left wrist fracture ( 1994 ) , and hypercholesterolemia .

depression
hypercholesterolemia
pleural thickening
anxiety
chronic left bundle branch block
allergies
left wrist fracture
asbestosis

tonsillectomy
vein stripping
adenoidectomy


the patient was begun on gentamicin , vancomycin and piperacillin , which was changed to gentamicin and ceftazidime .

gentamicin gentamicin piperacillin ceftazidime vancomycin


the patient does not recollect what her reaction to penicillin was .


the patient 's family history was significant for a brother with colon cancer .


heent examination was normocephalic and atraumatic .


the regimen included cyclophosphamide , daunorubicin , prednisone , vincristine and peg-asparaginase .

the regimen
peg-asparaginase
vincristine
daunorubicin
cyclophosphamide
prednisone


6) lactulose 30 milliliters p.o. q.2h. p.r.n. constipation .


platelets were 9,000 , hemoglobin 9.5 , temperature was 100.4 .


4) colace 100 mg p.o. b.i.d.


5) lasix 40 mg p.o. q day .


3) cefazolin one gram iv q.8h. x 13days .


a hickman catheter was placed and the patient was begun on chemotherapy .


8) miracle creamtopical q day p.r.n. skin irritation .


the patient 's discharge medications include the following :


temperature 98.2 , blood pressure 134/80 , respiratory rate 22 , pulse 102 .

respiratory rate
pulse
temperature
blood pressure


10) senna tablets , two tablets p.o. b.i.d.


9) sarna topical b.i.d. p.r.n. itching .


the patient was in her usual state of health until about three weeks prior to admission when she began to notice increased weakness and bruising .


cardiac exam revealed an s1 and an s2 and a diffuse 2/6 systolic murmur .


the patient 's liver function tests began to rise and she began to experience pulmonary symptoms including increased crackles .


12) citrucel one tablespoon p.o. q day .


the oropharynx was within normal limits with fillings and a partial upper plate .


16) robituss in ac five to ten milliliters p.o. q.h.s. p.r.n. cough .


the patient became constipated ; this resolved with laxatives .


13) k-dur 10 meq x three , p.o. b.i.d.


the patient was begun on nafcillin due to continued spiking .


the patient continued to spike and was enrolled in a randomized trial , the patient was randomized to ambisome antifungal treatment .


the patient 's physical examination revealed a well-developed , well-nourished white female in no apparent distress .


thepatient developed a possible drug rash and nafcillin was changed to ancef .


14) zoloft 25 mg p.o. q day .


pt 12.8 , ptt 19.1 .


peripheral smear revealed blasts of 62% .


the chest exam was clear to auscultation .


acute leukemia


there was decreased hearing bilaterally .


no headache , no nausea , vomiting or diarrhea .


the patient tolerated the chemotherapy regimen well .


the patient began to spike and a blood culture grew out staphylococcusaureus .


1) albuterol inhaler two puffs q.i.d. p.r.n. breathing difficulties .


7) magnesium hydroxide 30 milliliters p.o. q day .


the skin examination revealed the right breast had a dark two centimeter ecchymosis and the left medial thigh had two pale blue two centimeter macules .

pale blue two centimeter macules
a dark two centimeter ecchymosis


the patient had a smear there consistent with all .


the patient also had a history of platelet reaction .


2) calcium gluconate 1000 mg p.o. q day .


admitting labs were :


the neck had a full range of motion , no lymphadenopathy .


the patient began neutropenic on day five of induction .


heent examination notable for bilateral arcussenilis but otherwise unremarkable .


there is no clubbing , cyanosis or edema and her peripheral pulses were trace palpable .


she states this light-headedness is often associated with shortness of breath and diaphoresis occasionally with nausea .

diaphoresis
light-headedness
nausea
shortness of breath


lopressor 100 mg p.o. b.i.d. ; nifedipine 10 mg p.o. t.i.d. ; timoptic solution 0.5% os b.i.d. ; coumadin 1 mg alternating with 1.5 mg q.o.d. at q.h.s. and haldol 2 mg p.o. q.h.s. p.r.n. in the evening , only for agitation associated with confusion .

coumadin
nifedipine
lopressor
timoptic solution
haldol


the patient tolerated the procedure well and was found postoperatively to have some left upper extremity weakness on proximal greater than distal musculature .


ekg revealed a normal sinus rhythm with a rate of 69 , left ventricular hyper-trophy with poor anterior progression of r-waves .

left ventricular hyper-trophy
poor anterior progression of r-waves


upon discharge it was the recommendation of the cardiology team that the patient 's prothrombin time be monitored weekly and be kept at a ratio of 3-4 iu .


she was maintained on heparin therapy initially but this was quickly switched over to coumadin anticoagulation therapy which she will need to be on long-term for her aortic valve replacement .

coumadin anticoagulation therapy
her aortic valve replacement
heparin therapy


cardiac examination revealed a regular rate and rhythm with a normal s1 and s2 , 3/6 systolic murmur at the right upper sternal border , no gallop was detected .


she has a history of glaucoma and a questionable history of claudication in her legs as well as a history of hypertension .

glaucoma
claudication in her legs
hypertension


sodium 141 , potassium 5.0 , bun 18 , creatinine 1.0 , pt 12.3 , ptt 24 , wbc 7.6 , hematocrit 41 , platelets 278,000 .

platelets ptt pt creatinine sodium hematocrit potassium bun wbc


she was admitted and evaluated by the cardiac surgery service after having undergone cardiac catheterization which revealed a 70% stenosis of her left circumflex artery , 50% stenosis of the left anterior descending and 10% stenosis of the right coronary artery .


carotid angiography revealed left internal carotid stenosis of 90% , right internal carotid artery " critical stenosis " .


the pain and light-headedness is now severely lifestyle limiting and the patient requested evaluation for possible aortic valve replacement .


the patient has a history of exertional angina and chest pain associated with light-headedness for nine years which was noted to increase in frequency over the past year , then upon admission had light-headedness and chest pain with a dull pressure in her neck to her substernal area , with only minimal exertion such as " walking across the room " .

exertional angina
chest pain
light-headedness
chest pain
a dull pressure in her neck
light-headedness


she was taken postoperatively the icu where she was extubated on postoperative day number one and by 5-11-92 she was noted to have markedly increased use of her right side , resolving aphasia and she was transferred to the floor with the residual deficit only noted to be some left upper extremity weakness .

aphasia
the residual deficit
some left upper extremity weakness


she denies any vomiting , states that the episodes usually last about five minutes and are relieved with rest .


her neck showed no jvd , there was a slow carotid upstroke bilaterally , there were bilateral carotid bruits versus transmitted murmur .

jvd
a slow carotid upstroke bilaterally
transmitted murmur
bilateral carotid bruits


she also has a history of uterine fibroids , status post total abdominal hysterectomy .


she has known bilateral carotid disease , stated to be greater than 70% bilaterally .


on physical examination she was afebrile with a blood pressure of 170/100 , heart rate of 70 .

blood pressure
physical examination
heart rate


medications on admission were only aspirin p.r.n. and timoptic solution 0.5% to the left eye twice a day .

medications on admission
timoptic solution 0.5%
aspirin


on 05-01-92 she was taken to the operating room at which time she underwent an aortic valve replacement with a # 19 st. jude valve , coronary artery bypass graft times one with saphenous vein graft from the posterior descending artery to the obtuse marginal and right carotid endarterectomy .

right carotid endarterectomy
coronary artery bypass graft
an aortic valve replacement
# 19 st. jude valve
saphenous vein graft


1. carotid stenosis .


however , on 05-07-92 there was a a question of a new event with addition to the left upper extremity weakness , some noted right upper and right lower extremity discoordination .


she was begun on a heparin drip .


the patient is a 76-year-old female who was admitted to the medicine service on 04-29-92 with a past history significant for aortic stenosis and chest pain who presented for evaluation for aortic valve replace-ment .


she was extubated on postoperative day number one and otherwise had an unremarkable postoperative course with the exception of her left upper extremity weakness .


she is transferred to rockdempbanri hospital on 05-28-92 to continue her rehabilitation .


she underwent angiography on 5-9-92 which showed the right internal carotid artery to be patent , however there was highly significant stenosis of the left carotid artery and she was taken to the operating room later that day for a left carotid endarterectomy .


past medical history is as stated above , aortic stenosis , found to be critical on echocardiogram on 4-13-92 , done in otte a , new jersey and was found to have left ventricular hypertrophy and ejection fraction of 58% , no right heart wall motion abnormali-ties and an aortic valve gradient of greater than 100 .

right heart wall motion abnormali-ties
left ventricular hypertrophy
aortic stenosis

an aortic valve gradient
ejection fraction
echocardiogram


on 5-9-92 the right-sided symptoms worsened and she also had some elements of aphasia .

some elements of aphasia
the right-sided symptoms


2. aortic stenosis .


cardiac risk factors hypercholesterolemia , hypertension , no history of tobacco use , diabetes or family history .


on 05-05-92 she was noted to convert to atrial fibrillation which resolved spontaneously a few days later .


3. coronary artery disease .


she was feeding herself and was very enthusiastic and energetic in her participation in her rehabilitation activities .


there was only diffuse small vessel disease noted .


she was worked up aggressively with the physical therapy and occupational services , made good progress and began ambulating with assistance with a walker but with minimal assistance from an aid .


chest was clear to auscultation bilaterally .


on 05-04-92 she was evaluated by the neurology service , who recommended a ct scan , however no evidence of infarction was detected .


her abdomen was soft , nontender with good bowel sounds .


your patient was admitted under the care of fong , coney n with a preliminary diagnosis of perforation .


following evaluation and treatment , the patient 's disposition at the end of the visit was admitted as an inpatient to ph university of medical center .


the patient presented with a chief complaint of abd pain .


history , physical , neuro exam normal


monitor / return for nausea / vomiting , headache , visual / mental status changes or other concerns .

vomiting
nausea
headache
other concerns
visual / mental status changes


head trauma - mva


refrain from motrin at this time .


treatment rendered :


tylenol as needed .


3. k-dur 20 mg po q.day ,


she had had no further episodes of tingling in her fingers after the initial episode which had prompted us originally to draw the ionized calcium .


4. hypertrophic obstructive cardiomyopathy ,


the plan was to start her on heparin and coumadin and discontinue her heparin when her coumadin levels became therapeutic as judged by the prothrombin time / inr .

inr
her coumadin levels
the prothrombin time


this is an 83-year-old female with a history of hypertrophic obstructive cardiomyopathy , status post mitral valve replacement in 1988 , chronic atrial fibrillation , hypertension , who presents for parathyroidectomy .

hypertrophic obstructive cardiomyopathy
hypertension
chronic atrial fibrillation

mitral valve replacement
parathyroidectomy


7. norvasc 5 mg po q.day ,


the electrocardiogram showed atrial fibrillation with slow ventricular response and digitalis effect as well as left ventricular hypertrophy .

atrial fibrillation
digitalis effect
left ventricular hypertrophy
slow ventricular response


3. atrial fibrillation , she is status post cardioversion 3-25-94 ,


1. laparoscopic cholecystectomy 03/93 by dr. sapmal ,


at present , she can walk one to two blocks before having to stop because of shortness of breath .


6. right cheek basal cell carcinoma ,


2. hypertension ,


on the day of admission , the patient was brought to the operating room for parathyroidectomy .


she has noticed some generalized hoarseness in her voice for the past 5-6 months .


9. lopressor 50 mg po b.i.d. ,


7. glaucoma ,


5. osteoarthritis ; she is to receive bilateral total knee replacements at some time in the near future ,


impression was that this was an 83-year-old female with cardiac history , dyspnea on exertion , increased calcium and hyperparathyroidism who presents for parathyroidectomy .

increased calcium
hyperparathyroidism
dyspnea on exertion
cardiac history


there is no family history of parathyroid or thyroid diseases .


in addition , she has some dysphagia , particularly has had some difficulties with swallowing .

some difficulties with swallowing
some dysphagia


8. digoxin .25 mg po q.day ,


10. status post dilation and curettage ,


admission white blood count 4.3 , hematocrit 31.0 , electrolytes were all within normal limits , glucose 218 , prothrombin time on admission was 15.1 with inr of 1.5 , partial thromboplastin time 23.3 .

glucose
prothrombin time
partial thromboplastin time
inr
hematocrit
electrolytes
white blood count


9. timoptic 0.5% b.i.d. to both eyes ,


in addition , she is to follow up with her primary care physician to check her prothrombin time / inr as well as calcium , albumin and phosphate levels .

calcium , albumin and phosphate levels
her prothrombin time
inr


4. coumadin 2.5 mg po q.day which was last taken two days prior to admission ,


12. status post left breast biopsy .


however , on postoperative day number two , the patient in the afternoon noticed some tingling in her hands and also some tingling hear her perioral region .

some tingling in her hands
some tingling hear her perioral region


the patient is an 83-year-old female who presents for surgical evaluation for her hyperparathyroidism .


the head , eyes , ears , nose and throat examination is notable for pupils which have irregular border and are very sluggishly reactive .

irregular border
very sluggishly reactive


2. dilation and curettage in 1992 for polyps ,


7. history of glaucoma ,


in august of 1996 while the patient was at retelk county medical center for replacement of her knees bilaterally , and on preoperative evaluation she was noted to have a high calcium and therefore the surgery was canceled .

replacement of her knees bilaterally
the surgery


on physical examination , she is a pleasant woman in no acute distress .


1. lopid 600 mg po b.i.d. ,


further testing revealed hyperparathyroidism as evidenced by an elevated pth .


on postoperative day number five , the patient felt fine and had an inr of 1.9 with a prothrombin time of 16.6 .


6. lasix 40 mg po q.day ,


her pulse is 72 , irregularly irregular , blood pressure 96/60 , temperature 97.9 , respirations 18 .

respirations
temperature
her pulse
blood pressure


5. norvasc 500 mg po q.day ,


an ionized calcium was drawn which was low at 1.0 .


parathyroidectomy on 12-27-96 .


4. hypertrophic obstructive cardiomyopathy ,


5. rocaltrol 0.25 mg po b.i.d. ,


as a result , the patient was started on os-cal 250 mg po q.i.d. on postoperative day number three , her ionized calcium was 1.06 and her os-cal was increased to 500 q.i.d.


when walking outside , she stops multiple times because of shortness of breath .


4. os-cal 500 mg po q.i.d. ,


she gets short of breath walking up steps .


2. hypertension , she has had hypertension for 15 years ,


hyperparathyroidism .


the review of systems is significant for a history of dyspnea on exertion .


6. digoxin .25 mg po q.day ,


1. status post mitral valve replacement in 1988 .


however , her ionized calcium decreased to 0.97 and she was given one amp of calcium gluconate .


3. lasix 40 mg po q.day ,


she has a st. jude 's mechanical valve and has been on coumadin since then ,


no known drug allergies .


6. right cheek basal cell carcinoma to be removed in the future ,


8. non insulin dependent diabetes mellitus which was diagnosed in march , 1995 ,


she had no muscular weakness noted .


the patient reports that she will have revision of cataract surgery .


8. glucotrol 10 xl qam ,


she is guaiac negative on rectal examination .


7. lopressor 50 mg po b.i.d. ,


postoperatively , the patient did well and was able to cough and phonate completely with no changes from preoperative .


2. lopid 600 mg po b.i.d. ,


1. coumadin 5 mg po q.day , then she will follow up with her primary care physician and decide the dosage thereafter ,


hyperparathyroidism .


10. pilocarpine gel qhs to both eyes .


5. osteoarthritis ,


11. status post cataract surgery ,


10. glucotrol 10 mg qam .


cardiovascular exam :


the patient reports no masses in her neck .


4. cataract surgery .


iii / vi systolic click and irregularly irregular rhythm .

irregularly irregular rhythm
iii / vi systolic click


her calcium was 8.5 , albumin 3.6 , and phosphate 4.5 .


9. status post laparoscopic cholecystectomy ,


9. shingles .


3. left breast biopsy which was benign ,


8. non-insulin dependent diabetes mellitus ,


the right superior parathyroid gland was found to be markedly enlarged and consistent with an adenoma .


1. status post mitral valve replacement ,


2. k-dur 20 mg po q.day ,


3. atrial fibrillation ,


upper extremities are very brisk bilaterally and symmetrical 3+. there is positive tremor reflex on the left and absent on the right .

positive tremor reflex on the left
absent on the right


the patient is allergic to hydralazine , codeine , ace inhibitors , nifedipine and percocet .

ace inhibitors
codeine
percocet
hydralazine
nifedipine


ms. breunlinke is a 69 year-old right handed woman , status post surgical correction of a c-1 to c-2 dural avm in january , 1998 , now presenting with a one month history of increasing left sided weakness and pain with spasticity , occasional difficulty swallowing and abdominal pain .

pain
abdominal pain
increasing left sided weakness
spasticity
difficulty swallowing


anal tone is reduced .


lower extremities show patellar reflexes 3+ left , 4+ right , no cross deductor reflexes and absent ankle jerks .

cross deductor reflexes
patellar reflexes


hematocrit is 37.6 , platelet count is 148,000 .


sodium 140 , potassium 3.8 , chloride 100 , bicarbonate of 30 , bun of 13 , creatinine 0.8 , serum glucose 228 .

serum glucose
creatinine
bicarbonate
chloride
sodium
potassium
bun


on admission include cozaar 75 mg q.d. , coumadin 2 mg/1 mg alternate days , synthroid 175 mcg q.d. , zoloft 50 mg q.d. , zantac 150 mg b.i.d. , diabeta 25 mg q.d. , proctofoam 1% q.i.d. , demerol 100 mg q 6 p.r.n. , oscal 2 tabs t.i.d. , multivitamins and kcl supplements , dulcolax 5 mg q.d. , senokot 2 tabs q h.s. , metamucil 1 tablespoon b.i.d. , detrol 2 mg b.i.d. , neurontin 200 mg t.i.d. , hydrodiuril 12.5 mg q.d. , valium 10 mg q 8 p.r.n. muscle spasm , insulin by sliding scale and levofloxacin 500 mg q.d. beginning october 23 , 1999 .

diabeta
demerol
metamucil
zantac
valium
kcl supplements
zoloft
multivitamins
hydrodiuril
proctofoam
levofloxacin
coumadin
cozaar
proctofoam
insulin
synthroid
neurontin
senokot
detrol
dulcolax
oscal


rectal examination is nontender and stool is guaiac negative .


urinalysis from october 21 , is positive for citrobacter susceptible to ciprofloxacin , gentamycin , nitrofurantoin , tetracycline and bactrim .

nitrofurantoin tetracycline bactrim ciprofloxacin gentamycin


upon further review of dr. laymie fields , department of neuroradiology , review of the cervical spine on ct reveals no extrinsic compressive lesions impacting the spinal cord and no enhancing lesions of the spinal cord with contrast .

enhancing lesions of the spinal cord
extrinsic compressive lesions


this pain often follows bowel movement but does occur spontaneously .


pupils are 4-6 mm bilaterally , extraocular movements were full without nystagmus .


on admission , a ct scan of the head with and without contrast was performed , showing a missing posterior arch at c-1 and metallic clips at the craniocervical junction consistent with prior surgical intervention .


she was found to have intermedullary lesion at c1-2 level which on biopsy showed abnormal vasculature , hemosiderin deposit , leading in turn to the discovery of a dural arteriovenous malformation at that level which was surgically corrected .

abnormal vasculature
hemosiderin deposit
a dural arteriovenous malformation
intermedullary lesion at c1-2 level


the patient was also given valium 5-10 mg p.o. t.i.d. for muscle spasm .


the postoperative period was complicated by transient swallowing difficulty , increasing left sided weakness and urinary retention .

urinary retention
transient swallowing difficulty
increasing left sided weakness


no arteriovenous malformations are identified ; there is no evidence of recurrence of her former vascular malformation .

her former vascular malformation
recurrence
arteriovenous malformations


on admission , heart is regular rate and rhythm without murmur .


the right upper extremity shows generalized reduction in strength , 4/5 in all joints .


we recommend daily physical therapy and occupational therapy to maximize functional capacity with optimization of pharmacological regimen for spasticity including baclofen , valium and adequate analgesia .

adequate analgesia
valium
physical therapy
pharmacological regimen
baclofen
occupational therapy


she denies dysuria or excessive urinary frequency .


no intraspinal lesions are identified .


note , the patient is not a candidate for magnetic resonance imaging secondary to ferromagnetic intracardiac pacing device .


over the past several weeks she has also developed severe intermittent abdominal pain , localized to the suprapubic area , left greater than right , occurring intermittently .


significant for insulin dependent diabetes mellitus , atrial fibrillation , hypothyroidism , hypertension , depression , frequent urinary tract infections , neuropathic pain syndrome and osteoporosis .

hypertension
frequent urinary tract infections
neuropathic pain syndrome
osteoporosis
hypothyroidism
atrial fibrillation
depression
insulin dependent diabetes mellitus


cerebellar ; the patient demonstrates an intention tremor on finger to nose with the left hand .


the tone is markedly increased in bot legs with left greater than right .


she was originally admitted to the verg medical center in january , 1998 , because of a one year history of left sided weakness and spasticity .


abdomen is soft , with marked suprapubic tenderness and reduced bowel sounds .

reduced bowel sounds
marked suprapubic tenderness


the patient has diminished vibration and propioception in the left upper and lower extremity and decreased temperature , light touch and pinprick sensation in the right upper and lower extremity consistent with a high cervical spinal sensory level .


lungs are clear to auscultation bilaterally .


upon further review of ct and angiography results with neuroradiology and neurology service , it was decided that ct myelography was not indicated at this time .


as of the beginning of september , 1999 , she was able to swallow without difficulty , urinate without difficulty ( although bowel movements have been problematic ) .


electrocardiogram shows no p-waves .


there is no clonus on the right but sustained clonus ( 10-12 beats ) on the left .


prothrombin time is 15.9 with an inr of 1.7 .


the patient was given aspirin 325 mg p.o. q.d.


she was continued on demerol 50 mg q 6-8 hours p.r.n. for left arm and leg pain .


functionally , she was at the level of pre-gait training and able to stand and take several steps with upper body support .


over the past 4-5 weeks her functional level has progressively deteriorated .


left arm shows a flexor contracture and markedly increased tone .

markedly increased tone
a flexor contracture


the left upper extremity shows reduction in motor power ranging from 2/5 in the triceps , 4/5 in the biceps , and 3-4/5 in the wrists and hand intrinsics .


her left arm has developed a flexure contraction and she reports intermitttent pain in the left arm and leg which occurs both spontaneously and is also triggered by contact .


left sided spastic hemiparesis , status post surgical correction of c-1 , c-2 dural avm .


angiography performed on october 31 , 1999 , showed normal vascular distribution of the head and neck with no recurrence of arteriovenous malformation .


she has developed some new swallowing difficulty and since her transfer to a long term inpatient care facility , she has lost ten pounds .


coumadin was discontinued .


fine motor movements are slow but accurate in the left and right hands .


white blood count is 7,000 .


during this admission , the patient was started on baclofen 10 mg p.o. t.i.d. for spasticity .


the right arm shows moderate increased tone .


the patient feels this is secondary to her hemorrhoids , although it does not clearly localize to the rectum .


ptt is 24 .


following evaluation and treatment , the patient 's disposition at the end of the visit was admitted as an inpatient to ro woodma healthcare .


the patient presented with a chief complaint of epigastric pain / abd pain .


the patient 's preliminary admitting physician is priesdouet , ch j and the preliminary diagnosis is cholecystitis .


low lying placenta ; past medical history , history of ; urinary tract infection , history of

low lying placenta
urinary tract infection


active labor


height 66 heent normal neck normal breasts normal nipples normal chest normal cor normal abdomen normal extrem normal skin normal nodes normal vulva normal vagina normal cervix normal os normal adnexae normal uterus normal uterine size in weeks normal 12


vaginal delivery with second degree laceration


she delivered a 3550 gram male infant on 08/31/2004 at 09:33 pm with apgar scores of 9 and 9 at one and five minutes respectively at 41.0 weeks gestation via spontaneous vertex vaginal delivery .


multivitamins and folate ( fam pren forte )

multivitamins
multivitamins
folate ( fam pren forte )


routine post partum care


chorioamnionitis .


spontaneous vertex vaginal delivery


nuchal cord .


active labor .


following evaluation and treatment , the patient 's disposition at the end of the visit was treated and released .


the patient presented with a chief complaint of abd pain .


5) ppd anergic .


pt was 12.6 and ptt was 29 .


mr. breutzfarstxei is a 30 year old man with recently diagnosed acquired immunodeficiency syndrome and pneumocystis carinii pneumonia who presented with pneumonia , developed adult respiratory distress syndrome , and died in the hospital after failed efforts of ventilatory support .

pneumonia
adult respiratory distress syndrome
pneumocystis carinii pneumonia
acquired immunodeficiency syndrome


on admission , white count was 7.2 with 57% neutrophils , 40% lymphocytes , l mononuclear cell , and 1.6 eosinophils .

neutrophils
mononuclear cell
eosinophils
lymphocytes
white count


stool was sent for ova and parasites .


his arterial blood gas on 50% was po2 92 , pco2 24 , and ph 7.46 .


on 02/11/91 , the patient again appeared more comfortable this time with 50% facemask but then required more oxygen , dropped his o2 saturations , and was intubated on 02/11/91 .


the patient was also covered with erythromycin and gentamicin for coverage of community acquired pneumonias and gram negative rods .

gram negative rods
community acquired pneumonias


actually in reviewing the records at this point , it appears that pentamidine was not started initially so on the antibiotics of erythromycin and gentamicin , the patient 's respiratory status worsened and his ldh climbed so he began pentamidine on 02/10/91 .

erythromycin
the antibiotics
gentamicin
pentamidine
pentamidine


review of liver function tests revealed a cholestatic picture which was not previously found and it was felt that this was secondary to the bactrim which had been recently stopped anyway .


titers for cmv and epstein-barr virus were sent and a titer for toxoplasma was sent .


he required elevated ventilatory pressures with pips often above 60 .


at discharge after about two weeks post-extubation , he had an o2 saturation of approximately 95% on room air .


due to continued worsening pulmonary status and an overall grim prognosis , the family decided , in consultation with the medical team , to withdraw ventilatory support .


he initially did well after extubation and completed approximately two weeks of bactrim and a steroid taper .


the patient 's liver function tests appeared to improve .


however , on 02/10/91 , his respiratory rate increased and his oxygen saturation decreased .

his oxygen saturation
his respiratory rate


he was seen in flfdmc where he was noted to have jaundice and newly palpable liver edge .


soft with bowel sounds and there was mid epigastric and right upper quadrant tenderness .


he was actually intubated and underwent bronchoscopy where the diagnosis was made with a positive toluidine blue study .


alt was 181 , ast was 156 , ldh was 336 , alkaline phosphatase was 214 , and bilirubin was 12.7 total .

bilirubin
ldh
alt
ast
alkaline phosphatase


the patient 's abdominal ct scan showed no liver disease and no obstruction .


he was transferred to the intensive care unit on 12/12/90 on gentamicin , vancomycin , pentamidine , and prednisone .

pentamidine gentamicin prednisone vancomycin


revealed icteric sclerae , the oropharynx with extensive thrush , and an ulcer under his tongue .

an ulcer under his tongue
the oropharynx with extensive thrush
icteric sclerae


however , the patient 's respiratory status continued to decline and we were unable to maintain oxygen saturations above 80% even using reverse i to e ventilation , paralysis , sedation , and other modes of ventilation .

reverse i to e ventilation
sedation
other modes of ventilation
paralysis


the patient required 100% oxygen to maintain adequate oxygen saturations on the ventilator .


these were supported with blood products and hematology was consulted .


he was started on pentamidine , especially in light of the fact that it was felt that his liver function tests were due possibly to bactrim .


the patient actually developed decreasing counts with white count as low as 1.75 , hematocrit as low as 26 , and platelets as low as 68 noted on 02/15/91 .


showed regular rate and rhythm without murmurs , rubs , or gallops .


patient expired after the endotracheal tube was withdrawn at 6:40 p.m.


on presentation , the patient was a young appearing hispanic male in mild respiratory distress with a blood pressure of 140/90 , heart rate 120 , respirations 32 , and temperature 101 .

a blood pressure
heart rate
temperature
respirations


on 02/06/91 , he was seen in flfdmc and at that point , his temperature was noted to be 101.4 and he had malaise and diarrhea .


on 02/13/91 , the patient had a bronchoalveolar lavage performed which showed a toluidine blue with many pneumocysts noted .


in terms of pulmonary function , it was felt that one possibility was that the patient was a bactrim failure for pcp although this was unusual .


in terms of his liver abnormalities , it was felt that viral hepatitis was in the differential as well as several opportunistic infections of the liver but also was felt that bactrim could be a cause of these abnormalities .


sodium was 133 , potassium was 4.2 , chloride 100 , co2 19 , bun 21 , creatinine 1.2 , and glucose 122 .

glucose potassium sodium chloride creatinine bun co2


also of note at that point , hepatitis c virus serologies had come back positive .


the patient 's penile ulcer was cultured and grew positive herpes simplex virus and the patient was started on acyclovir .

positive herpes simplex virus
the patient 's penile ulcer


2) pneumocystis carinii pneumonia .


discussions were begun with the family regarding limits of supportive care .


1) hiv positive with a cd4 count of 74 .


they felt that it was most likely secondary to bactrim and these actually were getting better when the patient died .


1) acquired immunodeficiency syndrome .


bone marrow biopsy was not attempted .


on 02/08/91 , the patient called dr. seen because of increased shortness of breath and malaise .


had tubular breath sounds especially in the lower lung fields .


mr. breutzfarstxei was recently diagnosed with acquired immunodeficiency syndrome when he had pneumocystis carinii pneumonia on 01/17/91 .

acquired immunodeficiency syndrome
pneumocystis carinii pneumonia


he was given supplemental oxygen .


2) recent pcp .


patient underwent liver biopsy on 02/16/91 and the results of this were pending when the patient died .


an autopsy will be performed .


the patient was admitted for work-up of his cholestatic jaundice picture along with work-up for his pulmonary process and treatment of both .

his cholestatic jaundice picture
his pulmonary process


however , at this point , his liver function test abnormalities appeared more consistent with a cholestatic picture with his direct bilirubin being 12.1 and total being 14.1 .

a cholestatic picture
his liver function test abnormalities


there was no costovertebral angle tenderness .


4) venereal disease history .


3) adult respiratory distress syndrome .


his chest x-ray showed bilateral nodular infiltrates .


no other cultures grew out and the patient 's clinical status deteriorated .


he was admitted to the retelk county medical center at that time and was treated with bactrim and steroids .


his penis had a 1/2 cm ulcer with yellowish discharge .


he had no cervical adenopathy and his neck was supple .


3) status post right elbow surgery .


he had guaiac positive stools .


an autopsy was performed as per the family 's wishes .


( on 02/06 , his bilirubin had been 7.2 with 6 direct ) .


at that time , his oxygen saturation was only 90% on room air and his chest x-ray showed no change .


cultures were taken and he was sent out .


his oxygen saturation at that time was only 86% on room air and he was admitted .


initially , the patient did well in terms of his pre-status and required less oxygen .


fortunately , no evidence of baratroma was ever discerned .


following evaluation and treatment , the patient 's disposition at the end of the visit was admitted as an inpatient to daughtersvillshamen's hospital .


the patient presented with a chief complaint of hematuria .


the patient 's preliminary admitting physician is linkethore , hansverllen g and the preliminary diagnosis is hematuria .


the patient denies melena , hematochezia , nausea , and abdominal pain .

abdominal pain
nausea
melena
hematochezia


abdominal ct while in the emergency department revealed likely primary colorectal adenocarcinoma with multiple liver metastases .

primary colorectal adenocarcinoma
multiple liver metastases


3. question of history of avn or osseous necrosis


the patient received two units of packed red blood cells and the hematocrit rose to 30 the following day .


the patient is allergic to msg from which he gets hives .


the patient is a 71-year-old police chief who presents with painless jaundice x1 day .


biopsy was taken at colonoscopy on 7/5/99 .


the patient was to follow-up with the petersly hospital and medical center as an outpatient for further treatment .


glucotrol 10 q.a.m. and vitamins


the patient presented to the emergency department with a complaint of painless jaundice , weight loss , and fatigue .


also denies tenesmus .


iron 300 mg p.o. t.i.d. , glucotrol , acel 10 mg p.o. q.d. , and bactrim ss 1 tablet p.o. b.i.d.


he also noted a 23 pound weight loss in the past 11 months despite having an increased appetite .

an increased appetite
a 23 pound weight loss


1. type ii diabetes mellitus diagnosed 06/94 , well-controlled with last hemoglobin a1c 6.2


patient denies night sweats in the past month .


hematocrit was 24 in the emergency department .


his wife noted personality changes with increased irritability .

personality changes
increased irritability


the patient also complained of fatigue and " feeling down " .


the patient states that he is occasionally constipated .


2. vocal cord polyps


his condition is stable and he was discharged with the following medications :


4. history of hyperkalemia .


the patient was generally in excellent health with a past medical history significant only for noninsulin dependent diabetes mellitus who was presented with painless jaundice x2 days .

noninsulin dependent diabetes mellitus
painless jaundice


head ct was done with final results pending on discharge .


on the day prior to admission , the patient 's family noted that " he looked yellow " and presented to the lorough medical center 's emergency department this after noon .


the patient 's father died at the age of 83 of chf .


question rta type 4


a repeat chest x-ray done for dyspnea showed persistent pleural effusion with atelectasis versus pneumonia .

persistent pleural effusion
pneumonia
dyspnea
atelectasis


dilaudid 2 to 4 mg po q3h prn pain , ativan 1 mg po q12h prn anxiety , zofran 8 mg po q8h prn nausea , compazine 10 mg po q6h prn nausea , decadron 20 mg po q6h x 2 doses .

compazine decadron dilaudid ativan zofran


the patient has not obtained gynecologic care for 32 years until april 2004 when an increase in abdominal gerd and urinary symptoms lead her to initial consultation with dr. lentny farstnappsshee in gobrew street , denlandcobridclevena , west virginia 28880 .


she was told to make an appointment two weeks after her surgery for removal of her retention sutures .

her surgery
her retention sutures
removal


on postoperative day eight which is memorial day the patient was started on carboplatin-taxolchemo therapy , which she tolerated without complication .


at that time a pelvic ultrasound was performed showing extensive fluid and clear mass within the pelvi-abdominal cavity .


on postoperative day one , the patient 's urine culture came back with moderate e. coli .


included prinzide 12.5 mg po daily , albuterol inhaler prn


she was also started on decadron in preparation for her chemotherapy .


she was started on levofloxacin 500 mg po daily .


hypertension , asthma , obesity , history of heart murmur , hemorrhoids , whooping cough as a child .

obesity
hypertension
hemorrhoids
whooping cough
heart murmur
asthma


the patient developed ulceration after im injection .


tonsillectomy in 1947 , removal of a renal calculus in 1979 , cholecystectomy in 1986 .


the patient tolerated nasogastric tube clamping trials with high residuals in the 600 cc range .


her urine output subsequently increased .


on postoperative day four , the patient continued to have nasogastric tube in place .


total abdominal hysterectomy , bilateral salpingooophorectomy , bilateral lymph node dissection , omentectomy , lysis of adhesions , removal of mass from surface of transverse colon .

bilateral lymph node dissection
lysis
removal
omentectomy
total abdominal hysterectomy
bilateral salpingooophorectomy


at this point she had an elevated ca 125 at 440 and came to dr. chabechird for further consultation .


the patient was instructed to take 20 mg at 11 pm the night before her next chemotherapy and 8 am on the morning of chemotherapy .


her levofloxacin was continued .


on postoperative day two , her foley was discontinued .


she also had an episode of nausea with some emesis , after being treated with zofran with no relief , a nasogastric tube was placed which drained 1200 cc of bilious fluid .

some emesis
nausea
no relief
bilious fluid


achest x-ray done at that time showed left pleural effusion and small right pleural effusion , not pulmonary edema and left lower lobe consolidations .

pulmonary edema
left pleural effusion
small right pleural effusion
left lower lobe consolidations


she also has food allergies to raw vegetables as well as some shortness of breath and throat constriction with shrimp .

throat constriction
some shortness of breath
food allergies


in the postoperative recovery room the patient had a hematocrit of 29.2 with low urine output .


on postoperative day three , the patient had a port placed .


the patient was admitted on 05/16/2004 for bowel preparation before the surgery .


the report from the frozen section sent in the surgery came back with poorly differentiated adenocarcinoma , possibly serous carcinoma of the ovary .

poorly differentiated adenocarcinoma
serous carcinoma of the ovary


64-year-old g5p5 postmenopausal for 10 years with a history of two months of progressive abdominal distention , crampy abdominal pain , urinary frequency and diarrhea .

progressive abdominal distention
urinary frequency
crampy abdominal pain
diarrhea


hypertension , asthma for 10 years , no hospitalizations , obesity , history of heart murmur , hemorrhoids and whooping cough as a child .

hypertension
asthma
whooping cough
obesity
heart murmur
hemorrhoids


she also had one episode of shortness of breath .


remarkable for colon cancer in her mother and maternal grandfather .


on 05/17/2004 the patient underwent atotal abdominal hysterectomy , bilateral salpingooophorectomy , bilateral node dissection , omentectomy , lysis of adhesions , removal of mass from surface of transverse colon .

lysis
removal
omentectomy
atotal abdominal hysterectomy
bilateral salpingooophorectomy
bilateral node dissection


she was given 1 unit of packed red blood cell .


the patient was afebrile , her vital signs were stable and she maintained a good urine output .


she was started on clear fluids with a nasogastric clamped .


no regular breast self examination , has not had a mammogram .

a mammogram
regular breast self examination


demerol .


on postoperative nine , her jp drain was discontinued .


the patient was transferred to the floor without any complications .


colace 100 mg po bid , albuterol inhalers two puffs inhaled qid prn wheezing and asthma symptoms .


g5 , p5 normal pap smears , sexual active without dyspareunia .


ovarian cancer .


mri showed a large fluid filled abdomen with a relatively small mass measuring about 5 to 6 cm in the right pelvis .

a relatively small mass
a large fluid filled abdomen


he had episodes of bradycardia without subsequent fall in blood pressure at the beginning of his admission .

bradycardia
subsequent fall in blood pressure


no clubbing or cyanosis .


on january 5 , he had a chest xray with a left apicalpneumothorax but was stable on chest xray of january 7 .


however , given his rapid clinical decline , this was deferred and i do not suspect that he will be a candidate for this , as the degree of his decline bodes a poor prognosis for him .


maalox plus , extra strength , 15 cc p.o. q 6 hours prn indigestion ; magnesium sulfate ; sliding scale iv and potassium chloride , sliding scale iv .

maalox plus , extra strength
magnesium sulfate
potassium chloride


tylenol , 650 mg p.o. q 4 prn ; allopurinol , 100 mg p.o. q.d. ; peridex mouthwash , 10 ml b.i.d.; cholysteramineresin , 4 grams p.o. q.d. ; clotrimazole , one troche p.o. q.i.d. ; fentanyl patch , 100 mcg per hour topical q 72 hours ; glipizide , 10 mg p.o. q.d.; atarax , 25 operating table 50 mg p.o. q 6 to 8 hours prn itching ; regular sliding scale insulin ; kbl mouthwash , 15 ccp .o. q.d. prn mouth discomfort ; lactulose , 30 ml p.o. q.i.d. that was started on january 30 , for no bowel movements with instructions to continue until bowel movement and then decrease to b.i.d. or q.d. ; lidocaine , 2% , 10 ml ur q 3 to 4 hours prn for pain around foley site ; ativan , 0.25 to 0.5 mg iv q 4 to 6 hours prn anxiety with instructions to use caution .

itching
anxiety
bowel movements
pain around foley site
mouth discomfort

tylenol
clotrimazole
fentanyl patch
lidocaine
regular sliding scale insulin
glipizide
peridex mouthwash
lactulose
kbl mouthwash
atarax
ativan
cholysteramineresin
allopurinol


sodium 137 , potassium 4.5 , chloride97 , bicarb 24 , bun 124 , creatinine 4.1 , glucose 144 , ast 49 , alt33 , alkaline phosphatase 253 , total bili 1.6 , calcium 9.2 , magnesium 2.3 , albumin 3.4 .

chloride97
bicarb
ast
potassium
alkaline phosphatase
creatinine
calcium
sodium
total bili
albumin
magnesium
alt33
bun
glucose


lasix , 80 ; avandia , 4 b.i.d. ; glipizide , 10 b.i.d.; imdur , 30 ; allopurinol ; zocor , 20 ; prilosec , 20 , potassium , 40 ; oxycontin , 30 b.i.d.; subcutaneous heparin ; unasyn , 1.5 grams q 6 ; combivent and morphine prn .

combivent
prilosec
lasix
morphine
avandia
zocor
oxycontin
glipizide
subcutaneous heparin
allopurinol
unasyn
imdur
potassium


the plan will be to continue to try to alternate albumin and lasix to mobilize his fluid .


he received a two week course of broad spectrum antibiotics and will be maintained on levofloxacin iv for prophylaxis against sbp .

broad spectrum antibiotics
prophylaxis
levofloxacin iv


this had to be performed by ir because the pocket was too deep to access from the bedside .


on january 1 , a chest tube was placed for a loculated pleural effusion .


he had experienced some constipation for the few months prior with lighter colored stools , darkened urine and fatigue for months with increased shortness of breath , orthopnea and dyspnea on exertion .

some constipation
lighter colored stools
dyspnea
orthopnea
increased shortness of breath
darkened urine
fatigue


hydrocortisone , 1% topical cream q 6 to 8 hours prn itching .


cultures were negative and onlyon one gram stain did it show rare gram negative rods .


discussion , at that point in time , should occur with the family about comfort measures and about weaning him from his medications to make him more comfortable .


white blood count 4.36 , hematocrit 26.1 with platelets of 107,000 , mcv 81 .

platelets
hematocrit
white blood count
mcv


neurologic examination - alert and oriented x 3 , slurred and slow speech , distractable .


an ercp performed there showed a long segment of distal narrowing of the common bileduct and a transhepatic biliary drain was placed there on december 29 .


the patient had signs and symptoms develop of sbp , also with an elevated white count .

signs
an elevated white count
symptoms
sbp


chest xray is still consistent with volume overload .


chest xray was consistent with pleurodesis .


levofloxacin , 250 mg p.o. q.d. ; albuterol and atrovent nebs q 4 to6 hours as needed prn wheeze .

levofloxacin
albuterol and atrovent nebs


from a pulmonary standpoint , he continued to complain of shortness of breath .


this is a 61 year old male with a history of diabetes , coronary artery disease , hepatitis c , and asthma who was diagnosed recently with pancreatic cancer after he presented to seph'sju memorial after a motor vehicle accident .

diabetes
pancreatic cancer
coronary artery disease
hepatitis c
asthma


he will be maintained on levofloxacin for prophylaxis against sbp .


the patient 's abdominal fluid cell counts showed 2400 white blood cells , 500 red cells with 82 polyps , 11 lymphs , 7 monos .


he is also on reglan , 10 mg p.o. q h ; miracle topical cream to affected area ; also sarna , topical cream , b.i.d.

sarna , topical cream
reglan
miracle topical cream


his pain here has been controlled , initially on oxycontin with morphine for breakthrough pain .


his appetite is decreasing somewhat as his disease process progresses , therefore , we have liberalized his diet for him to take what he wishes .


as he becomes progressively more somnolent , this will likely need to be switched to iv pain medications only .


echocardiogram showed 50% ejection fraction with mild mitral regurgitation .


chest had diffuse crackles bilaterally halfway up .


the patient initially came for workup of pancreatic cancer with a questions of palliative chemotherapy .


ocean spray q.i.d. to nares prn nasal dryness .


multivitamin , one tab q.d. morphine immediate release , msir , 15 to 30 mg p.o. q 2 to 3 hours prn pain .

multivitamin
msir
morphine immediate release


coronary - irregular pvcs , s1 , s2 normal , positive systolic murmur at the left upper sternal border radiating throughout .


however , with persistent abdomen distention , there is likely restrictive deficit and , in addition , after each tap , he at times became hypotensive and with some mild fluid resuscitation decompensated with pulmonary edema , requiring both albumin and lasix to try to mobilize third space fluids .

third space fluids
hypotensive
pulmonary edema
restrictive deficit
persistent abdomen distention

some mild fluid resuscitation
lasix
albumin


asthma .


the patient gets very somnolent with ativan .


chest ct revealed a pulmonary nodule .


he had a creatinine of 4.0 on admission and this decreased down to the mid ones with fluid , currently at 1.7 on discharge .


hypertension .


abdomen was distended , tympanitic , mildly tender epigastrium and right lower quadrant .


on january 4 , he had a desaturation .


the patient had an elevated bilirubin on admission with decreased output of biliary drain .


he was treated broadly with amp , levo and flagyl .


no rebound or guarding .


the patient was transferred from an outside hospital for a second opinion regarding workup of his pancreatic cancer .


clinically , this was consistent with sbp , although unfortunately , fluid was never sent for cytology and a lot of those white cells are most likely due to his cancer .


he denied any fevers , chills or night sweats .


abdominal ct revealed a 3.0 to 4.0 centimeter lesion in the pancreatic head .


given that he will need continued taps,


his apical pneumothorax from the outside hospital had resolved .


the drain was replaced over the wire , 8-10 by ir , when it was accidentally removed .


diabetes .


from a heme standpoint , he presented anemic and with an elevated pt inr .


coronary artery disease with congestive heart failure .

coronary artery disease
congestive heart failure


the patient had reported an approximately 30 pound weight loss in six weeks .


from his urinalysis , he has mostly a prerenal state .


hepatitis c .


he has nystatin suspension mouthwash , 10 cc swish and swallow q.i.d. he gets serax , 15 to 30 mg p.o. q h.s. prni nsomnia .


on january 2 , pleurodesis was performed .


his ca99 was normal .


however , this resolved on its own over the hospital course .


psoriasis .


his avandia was discontinued secondary to the side effect profile .


the morphine is for breakthrough pain .


heart rate was 78 , blood pressure 98/50 , respiratory rate of 32 , satting 91% on four liters .

blood pressure
heart rate
respiratory rate
satting


he was treated with broad spectrum antibiotics for a 14 day course for clinical sbp .


his inr normalized , however , unfortunately , he developed bilateral deep venous thromboses during his hospital course and will be maintained on lovenox .


he is being maintained on glipizide and sliding scale insulin .


brain ct was negative , as was a bronchoscopy with lavage .


pancreatic cancer


neck was supple with no lymphadenopathy .


he was ruled out for a myocardial infarction .


he did not show any episodes of bradycardia throughout the remainder of his hospital course .


extremities had 2+ bilateral lower extremity edema to knees .


he is also on a fentanyl patch , 100 mcg q 72 hours .


heent - normocephalic / atraumatic , extraocular movements are intact , pupils equal , round and reactive to light and accommodation .


he also required ffp initially to reverse his coagulopathy .


theyalso had diabetes and hypertension .


vq was indeterminate .


however , he does require diuresis to prevent increased volume overload in his lungs from his hypoalbunemic state .

increased volume overload
his hypoalbunemic state


in general , this is an obese male in mild respiratory distress .


he required a few transfusions during his hospital course .


lenis were negative at that time .


mother and father died of heart failure .


significant for recently diagnosed pancreatic cancer .


diabetes .


the patient was afebrile .


gout .


sister with stomach cancer .


he underwent abdominal paracentesis approximately two times a week for therapeutic .


hypercholesterolemia .


if severe , then proceed to er for evaluation .


amoxicillin 1,000 mg po bid x 28 doses


her pain currently is 5/10 .


other diagnosis ; conditions , infections , complications , affecting treatment / stay obesity htn high cholesterol tobacco fhx of cad ett 12/94 ( - ) ischemia echo 02/89 nl ett 03/89 , 07/90 c / w nd ische

ischemia
cad
high cholesterol
nd ische
htn
obesity


mri hida ct


pt was seen by gi on 13 egd was performed hd2 which was negative for gastritis , stricture or ulcer .


afferent limb of the roux en y anastamosis was visualized however the efferent limb could not be explored .


override added on 01/23/05 by dainsaylesnoort , ager , m.d. , ph.d. on order for clarithromycin po ( ref # 99052380 )


pt had hida scan which was negative for obstruction , and ct was unremarkable .


if fevers , chills , nausea , vomiting , diarrhea , increasing pain with food please call dr. gaetzfreierm 's office or pcp .

vomiting
increasing pain with food
fevers
nausea
diarrhea
chills


simvastatin and clarithromycin


wellbutrin sr ( bupropion hcl sustained release ) 200 mg po bid


percocet , iv contrast , lisinopril , atenolol

percocet
lisinopril
atenolol
iv contrast


the pt is a 55yo f s / p roux en y gbp in 12/20 presenting to the ed this am c / o mod severe midepigastric pain .


she has also had intermittent post-prandial nausea / satiety for which she had been scheduled for an outpt egd with gi on 2/8 .


plans to follow up with outpatient mra to rule out ischemic causes of post prandial pain , as well as hida with ck challenge to evaluate for biliary dyskinesia without stasis .


takes hubby 's sl ntg barium swallow 04/89 ( - ) ugi 06/91 ( - )


please continue taking the antibiotics for h. pylori for full course ( 26 more days ) .


esomeprazole 20 mg po bid x 28 doses


ros ( - ) emesis / brbpr/melena / fever/chills / sob .


lamictal ( lamotrigine ) 150 mg po bid


gastritis


potassium chloride slow rel. ( kcl slow release ) 40 meq po qd as per sc


hydrochlorothiazide 25 mg po qd zocor ( simvastatin ) 40 mg po qhs

hydrochlorothiazide
zocor ( simvastatin )


pt will finish course of h. pylori treatment as well .


for h.pylori .


each 20 meq dose to be given with 4 oz of fluid cozaar ( losartan ) 50 mg po qd


h.pylori tx .


simvastatin and clarithromycin


clarithromycin 500 mg po bid x 28 doses


pt was found to be h. pylori positive and therefore was started on empiric treatment .


she notes that she has had this pain since thursday , and that it becomes much worse within 15 min of consuming a meal .


she describes the pain as band-like / radiating to both sides but not the back .


h. pylori tx .


will need to call for outpatient mra and hida with cck challenge to evaluate biliary system and mesenteric vasculature .


principal discharge diagnosis ; responsible after study for causing admission ) gastritis


pt was tolerating regular diet by hd4 , and gi felt that further workup could be continued as an outpatient .


on 5-29-00 , she underwent thyroidectomy with removal of a 3.3 centimeter right lobe microfollicular adenoma and left lobe 6 mm .


papillary carcinoma .


her deep tendon reflexes are symmetric .


chronic lymphocytic thyroiditis , status post right total and left subtotal oophorectomy , asthma , migraine , history of droperidol allergy .

migraine
chronic lymphocytic thyroiditis
droperidol allergy
asthma


there was no evidence of any middle compartment lymphadenopathy or spread of the tumor outside the thyroid .

any middle compartment lymphadenopathy
the tumor


include a blood pressure of 174/84 , respirations 14 , pulse 89 , temperature 98.9 , o2 sat 98% .

respirations
pulse
a blood pressure
temperature
o2 sat


left thyroid occult papillary carcinoma .


carotid pulsations are normal without bruit .


she has no dyspnea or dysphagia .


she has developed symptoms from a right lower dominant nodule with pressure discomfort in the neck .

pressure discomfort in the neck
a right lower dominant nodule
symptoms


abdomen is soft , non-tender , with no organomegaly or masses .


her sutures were removed on postoperative day # one , at which time she went home in satisfactory condition .


on physical exam , she is a healthy-appearing female with a normal voice and no exophthalmos .


there is no family history of thyroid cancer .


the patient is a 51 year-old female , with a non-toxic multinodular goiter .


she has not received prior radiation exposure .


clear to auscultation and percussion .


palpation of the neck discloses a multinodular goiter , larger on the right side , with no associated cervical lymphadenopathy .

associated cervical lymphadenopathy
a multinodular goiter


vital signs :


non-toxic multinodular goiter .


thyroidectomy .


her heart rhythm is regular with a normal s1-s2 , and no murmur .


1. synthroid 0.125 mg. daily .


bilaterally without stridor .


3. she will remove the neck suture lines steri-strips in 10 days .


abnormal pap test , history of ; bacterial vaginitis ; contraception management ; hiv counseled


mouth normal neck normal thyroid wnl breasts normal no distinct masses nipples normal inverted [ b ] , evert w / stimulation chest normal lcta cor normal rrr abdomen normal gravid extrem normal skin normal nodes normal vulva normal no lesions , white d / c at introitus vagina normal sml amt thin white d / c ph 4.5 , koh +amine , ns +clue , neg trich cervix normal 1/100/0 srom clear os normal closed adnexae normal no palp masses , nt uterus normal gravid uterine size in weeks normal term rectum normal no ext lesions

white d / c at introitus
distinct masses
inverted
lesions
ext lesions
palp masses
sml amt thin white d / c
srom


she delivered a 3680 gram male infant on 10/12/2004 at 10:17 pm with apgar scores of 9 and 9 at one and five minutes respectively at 40.0 weeks gestation via spontaneous vertex vaginal delivery .


metronidazole tablets ( flagyl ) ; multivitamins and folate capsules ( stuart prenatal with folate )


vaginal delivery with second degree laceration


srom in labor


spontaneous vertex vaginal delivery


srom in labor .


antimicrobial therapy


srom .


32 y / o woman with h / o anxiety and depression and prior suicide attempt presents with tca and celexa overdose , tremulous / light-headed , felt better post charcoal .

anxiety
tremulous
tca and celexa overdose
prior suicide attempt
depression
light-headed


3/7 -- repeat hco3 24 and 26 without bicarb drip .


folate ( folic acid ) 1 mg po qd zantac ( ranitidine hcl ) 150 mg po bid mvi therapeutic w / minerals ( therap vits / minerals ) 1 tab po qd thiamine hcl 100 mg po qd


principal discharge diagnosis ; responsible after study for causing admission ) tca overdose


other diagnosis ; conditions , infections , complications , affecting treatment / stay depression ( depression )


tca overdose


rehabilitation


no ekg changes , marijuana in urine , hco3 22 .


transferred to floor on day of admission with no acute medical issues ; awaiting psych eval .


ekg without changes .


dr. ee , patient to arrange , no known allergies


not actively suicidal .


of note , nortriptyline level came back as 43 ( subtherapeutic -- normal 50-150 ) .


best team eval found bed at psych rehab facility .


your patient was admitted under the care of sapsclyss , leo r with a preliminary diagnosis of pneumonia , .


following evaluation and treatment , the patient 's disposition at the end of the visit was admitted as an inpatient to heaonboburg linpack grant medical center .


the patient presented with a chief complaint of wheezes .


1. right sided sciatica procedure :


his examination was completely unremarkable .


he was admitted , taken to the operating room where he underwent l5-s1 right hemilaminectomy and discectomy .


over the next three days he increased his activity gradually , was able to do stairs with physical therapy and had pain which could be controlled with oral analgesics .


in september 1992 ct myelogram showed a lateral l-1 s-1 disc bulge and small l-4-4 bulge .

a lateral l-1 s-1 disc bulge
small l-4-4 bulge


the patient is a 42 year old gentleman who suffered lower back pain during an accident at work in 1990 .


right laminectomy and discectomy by dr. small , neurosurgery .


this gradually increased until june 1992 where he had recurrent severe right sided sciatica .


he is discharged on percocet , colace and motrin .


he has had no change in pain in the last few months .


discharge orders ( medications instructions to patient , follow-up care ) :


multivitamins and folate


current smoker , history of ; depression , history of ; isoimmunization , rh ; undesired fertility

undesired fertility
isoimmunization , rh
depression


early labor / rule out labor


nuchal cord , x 1- reduced prior to delivery .


home with self-care ( routine discharge )


spontaneous vertex vaginal delivery


this 22 year old gravida 4 para 2012 was admitted to the naliheall county memorial hospital obstetrical service on 10/29/2003 at 11:14 pm for the indication ( s ) : early labor / rule out labor .


pp sterilization


normal vaginal delivery


she delivered a 3263 gram female infant on 10/30/2003 at 05:03 am with apgar scores of 8 and 9 at one and five minutes respectively at 40.1 weeks gestation via spontaneous vertex vaginal delivery .


electrocardiogram showed sinus tachycardia at a rate of 123 beats per minute compared to previous electrocardiogram of 1/29 there were no significant changes .


he was diuresed with intravenous lasix to which he responded with at lease a 2l urine output on the first day and 1.5l the second day .


history of colon cancer status post hemicolectomy .


there were no wheezes or rhonchi .


the patient was continued on antibiotics for possible pneumonia .


a chest x-ray showed clearing of the opacities in the chest x-ray that were consistent with pulmonary edema because he continued to have some abnormality in the right lower lobe .


the antibiotic chosen was levaquin 500 mg 1 tab per day .


the patient had missed his usual monthly change of his suprapubic catheter and felt discomfort and noticed some blood at the site of the catheter .


the patient 's abdominal pain should be followed over the next week or so in case it does not respond to prilosec .


5. combivent 3 puffs four times per day .


no orthopnea .


the ticarcillin was stopped after two days when it was felt that he did not have a serious pneumonia .


the patient denies any recent upper respiratory infections , no fevers , no chills , no change in cough , sputum .

change in cough
chills
fevers
recent upper respiratory infections
sputum


blood urea nitrogen 11 , creatinine .6 , uric acid 3.0 , alkaline phosphatase 78 , creatinine phosphokinase isoenzymes too low , hematocrit 41 , white blood cell count 11.6 .

white blood cell count
blood urea nitrogen
creatinine
uric acid
hematocrit
alkaline phosphatase


the patient was given respiratory therapy in the way of nebulizer treatments in the oaksgekesser/ memorial hospital emergency room because of a longstanding desire by patient and family to refrain from intubation to be considered do not resuscitate .

nebulizer treatments
intubation
respiratory therapy


1. ativan 1 mg po twice a day .


the patient had been taking his usual medications and using his nasal oxygen at home .

his nasal oxygen at home
his usual medications


no paroxysmal nocturnal dyspnea .


7. sorbitol 30 cc every other day .


the patient did have any nausea , vomiting or evidence of gastrointestinal bleeding .

nausea
vomiting
gastrointestinal bleeding


he needed to go to a rehab facility for continued respiratory therapy and for physical therapy to increase his muscle strength .

physical therapy
a rehab facility
continued respiratory therapy


coronary artery disease .


this is a 76 year old white male with severe chronic obstructive pulmonary disease who has had several recent admissions to oaksgekesser/ memorial hospital for respiratory insuffiencey most often secondary to pneumonia .


7. prednisone 40 mg per day to be tapered over two weeks .


congestive heart failure .


these were thought to be consistent either with pneumonia or asymmetric pulmonary edema .


i think his breathing was as good as to be expected with the amount of severe chronic obstructive pulmonary disease he had .


his initial blood gases on 40% 02 was p02 102 , pc02 115 , ph 7.11 .


4. history of colon cancer with a colectomy in the past .


however he was transferred to the medical intensive care unit where he received continuous respiratory therapy in theway of albuterol nebulizers as well as nasal oxygen , intravenous steroids and intravenous antibiotics .

intravenous steroids
intravenous antibiotics
albuterol nebulizers
continuous respiratory therapy
nasal oxygen


heart exam revealed a soft s1 and s2 , no murmur was heard , no s3 .


the patient 's respiratory status continued to improve but towards the last 2-3 days of his hospitalization the amount of improvement was minimal .