his penrose drain was discontinued at this time .


his laboratories were checked and his hematocrit was noted to be stable .


he was discharged home with a foley catheter and he will follow-up with dr. ross in one to two weeks .


on postoperative day number one , he was administered 1 mg coumadin per protocol as well as on the operative day 1 mg of coumadin .


the patient tolerated the procedure well .


status post radical retropubic prostatectomy .


dr. marie anderson performed the surgery .


the patient is a 64 year old gentleman with a history of elevated psa , prostate cancer .


he was diagnosed with needle biopsy on either side of the prostate with 3+3 equals 6 on the right side and 3+4 equals 7 on the left side .


the patient underwent radical retropubic prostatectomy on 2012-01-20 .


prostate cancer .


72 year old man with intraparenchymal bleed s/p fall


pt - 15.0 * ptt - 31.3 inr(pt) - 1.5


decision to continue dobhoff at rehab given continued clinical improvement and his poor candidacy for g/j tube .


indication : intraparenchymal hemorrhage after fall .


mental status improved with the discontinuation of his bensodiazapines .


extensive carotid arterial calcifications are present in the bulb regions bilaterally .


patient tolerated decreasing ventillary support.


2014-11-11 : tracheostomy performed without complication .


prevertebral soft tissue swelling cannot be excluded secondary to intubation .


cva 2012 w/ right sided weakness


plt count - 207


impression : minimally displaced , comminuted fractures of the left c7 and t1 transverse processes .


in tsicu , developed mrsa pneumonia with question of aspiration , treated zosyn --> vanc / levo --> then 2 week course of linazolid with resolution of fevers and decreased pulmonary secretions .

aspiration
mrsa pneumonia
decreased pulmonary secretions
fevers


wbc - 6.5 rbc - 3.68 * hgb - 11.6 * hct - 32.5 * mcv - 88 mch - 31.5 mchc - 35.6 * rdw - 13.6


there is no atlantoaxial subluxation .


ct c - spine w/o contrast ; ct reconstruction


type - art temp - 36.6 rates - 14 / tidal vol - 550 peep - 5 o2 - 100 po2 - 416 * pco2 - 39 ph - 7.41 total co2 - 26 base xs - 0 aado2 - 279 req o2 - 52 - assist / con intubated - intubated

total co2
po2
pco2
temp
ph
rates
aado2
tidal vol
base xs
req o2


asa - neg ethanol - neg acetmnphn - neg bnzodzpn - neg barbitrt - neg tricyclic - neg

bnzodzpn ethanol asa tricyclic barbitrt acetmnphn


ct c - spine w/o contrast


bnzodzpn - neg barbitrt - neg opiates - neg cocaine - neg amphetmn - neg mthdone - neg

amphetmn mthdone cocaine opiates barbitrt bnzodzpn


conclusion : improvement in congestion from edema with no worsening , but no significant improvement , in the right upper lobe pneumonia .

edema
congestion
the right upper lobe pneumonia


8. bisacodyl 5 mg tablet , delayed release ( e.c. ) sig : two ( 2 ) tablet , delayed release ( e.c. ) po daily ( daily ) as needed for constipation .


7. docusate sodium 150 mg / 15 ml liquid sig : one ( 1 ) po bid ( 2 times a day ).


5. metoprolol tartrate 25 mg tablet sig : one ( 1 ) tablet po tid ( 3 times a day ).


2014-10-21 09:35 am urine


6. digoxin 125 mcg tablet sig : one ( 1 ) tablet po daily ( daily ).


3. lansoprazole 30 mg susp , delayed release for recon sig : one ( 1 ) po daily ( daily ).


4. linezolid 600 mg tablet sig : one ( 1 ) tablet po q12h ( every 12 hours ): last dose 2014-11-20 .


ulcerative colitis w/ colostomy


2. lisinopril 15 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


pacemaker


2. ovoid 18 - mm density within the atrium of the right lateral ventricle .


serial ct head revealed decreased blood through 2014-11-14 .


findings were discussed with dr. leanne vazquez at the time this study was performed , but the study was not dictated until the morning of 2014-10-22 , due to pacs malfunction .


technique : noncontrast cervical spine ct .


1. heparin ( porcine ) 5,000 unit/ml solution sig : one ( 1 ) injection tid ( 3 times a day ).


positioning limits assessment of alignment due to extreme head tilting to the right , but this is likely the best obtainable secondary to intubation and nasogastric tube placement .


bronchoscopy 2014-11-05


progressed adequately with physical / occupational therapy , however was noted to develop an early bilateral upper extermity contracture at the elbows and wrists .


there is diffuse brain atrophy and chronic microvascular infarction throughout the white matter .


by report , the patient has an outside study .


supporting tubes and lines are in unchanged position and the patient has a single lead pacemaker projected on the left .

supporting tubes and lines
a single lead pacemaker


technique : non-contrast head ct .


comparison : no prior studies are available .


assess for hemorrhage .


there is opacification of the posterior nasal cavity and nasopharynx but an ng tube is present , and the patient is intubated .


left rib fractures 05-22


there is a small amount of blood layering in both lateral ventricles , and this has decreased since the previous study .


bleed ?


reason : bleed ?


c7 & t1 mimimally displaced transverse process fracture


there are numerous areas of decreased attenuation in the periventricular and subcortical white matter of both cerebral hemispheres , indicating chronic microvascular infarction .


multiple left-sided rib fractures are seen .


ct head w/o contrast


there is no evidence of surrounding edema .


subarachnoid hemorrhage w/ bilateral intraventricular hemorrhage

bilateral intraventricular hemorrhage
subarachnoid hemorrhage


located within the atrium of the right lateral ventricle is an 18 x 10 mm nodular area of increased density which is separate from the choroid plexus .


intubated and sedated for desats on 2014-10-27 .


non-contrast head ct : there is a small amount of hemorrhage within the occipital horns of both lateral ventricles , right greater than left .


left t1 transverse process fracture


the ventricles do not appear dilated relative to the sulci , and there is no shift of normally midline structures .


9. magnesium hydroxide 400 mg / 5 ml suspension sig : thirty ( 30 ) ml po q6h ( every 6 hours ) as needed for consitpation .


note : this study was initially performed on the morning of 10-21 , and is being dictated on the morning of 10-22 due to pacs malfunction .


there is no evidence of subarachnoid hemorrhage or acute major vascular territorial infarction .


should this become available , an addendum will be issued to this report following the comparison with the outside examination .


tracheostomy 2014-11-11


iodine ; iodine containing


some interstitial edema still persists , but there is no central pulmonary vascular congestion .

some interstitial edema
central pulmonary vascular congestion


noncontrast cervical spine ct : there are minimally displaced and comminuted fractures through the left c7 and t1 transverse processes .


failed swallow study x 2 in early november .


note : this study was initially performed on 2014-10-21 .


no evidence of extension into the foramina transversaria .


admitted to tsicu for subarachnoid hemorrhage and multiple spinal fractures .

multiple spinal fractures
subarachnoid hemorrhage


ct head w/o contrast


also noted is sclerosis and opacification of the visualized left mastoid air cells and mastoid tip , likely chronic inflammatory


portable supine chest radiograph shows improvement in edema compared to studies from four and five days earlier with no significant radiographic change in right upper lobe consolidation consistent with pneumonia .

pneumonia
right upper lobe consolidation
edema
significant radiographic change

studies
portable supine chest radiograph


disease .


biapical lung scarring and mild bronchiectasis are present .

mild bronchiectasis
biapical lung scarring


supporting lines and tubes in unchanged position .


this could represent either an atypically located blood clot or an intraventricular mass , and further evaluation with contrast - enhanced mri of the brain , when clinically feasible , is recommended .

an intraventricular mass
an atypically located blood clot


atrial fibrillation ( on coumadin )


1. small amount of intraventricular hemorrhage .


history : trauma , congestive heart failure , fever , pneumonia .

trauma
fever
congestive heart failure
pneumonia


there is a remote right frontal infarct .


you must continue to wear your cervical collar for the next 4 weeks ( through 12-11 ).


opacified and sclerotic left mastoid air cells are noted .


there is no skull fracture .


there is also an old right frontal lobe cortical infarction .


a small right occipital lobe chronic infarction is also evident .


there is some fluid or mucosal thickening in the ethmoid and sphenoid sinuses .


hypertension


no new hemorrhage is observed .


there is opacification of the mastoid air cells , greater on the left than the right .


altered mental status


coronary artery disease


reason : altered mental status


comparison is made to a previous study from 2014-10-27 .


indication : 72-year-old male with altered mental status .


cataracts , s/p cataract surgery


technique : axial noncontrast ct scans of the brain were obtained .


chest ( portable ap )


occasionally required haldol / ativan at night for agitation .


reason : fever , f/u infiltrte


communicating by speech s/p pmv placement .


72 yo m with rib fx s/p trauma , failure on previous cxr , now with fever .


glucose - 126 * urea n - 9 creat - 0.8 sodium - 135 potassium - 3.4 chloride - 99 total co2 - 25 anion gap - 14

creat
sodium
potassium
glucose
urea n
chloride
anion gap
total co2


impression : no new cortical territorial infarction or hemorrhage is identified .

hemorrhage
new cortical territorial infarction


there is decreased intraventricular blood , compared to the previous study , and there are no signs of hydrocephalus .

decreased intraventricular blood
hydrocephalus


s/p turp


evaluated by orthopedic spine surgeons with recommendations for soft c-collar for comfort .


ct head remained stable for sah .


calcium - 8.2 * phosphate - 2.1 * magnesium - 1.9


cardiac size is unchanged .


the amount of fluid layering at the apices and the pleural spaces appear slightly decreased .


calcification is seen at both carotid bifurcations .


fever , f/u infiltrte


no air-fluid levels to suggest occult facial fractures .


his right tib / fib fracture was repaired by orthopedics on 10-27 ; postoperatively there were no complications .

complications
his right tib / fib fracture


he was transfused with 3 u packed cells for a hematocrit of 21 , post transfusion hct was 26.1 ; there was a questionable transfusion reaction at the end of his first unit of packed cells ; he did subsequently receive the remaining 2 units without any further reaction .

any further reaction
transfusion reaction

3 u packed cells
his first unit of packed cells
the remaining 2 units


he was fitted with a hinged mcdonald brace for his lle .


return to the emergency room if you develop fevers , chills , severe headaches , visual disturbances , nause , vomiting and / or any other symptoms that are concerning to you .

vomiting
nause
severe headaches
any other symptoms
fevers
visual disturbances
chills


upon arrival gcs 15 , alert and oriented x3 .


subdural hematoma


inform the office that you will need a repeat head ct scan for this appointment .


his neurosurgical issues were nonoperative ; he was loaded with dilantin ; serial head ct scans were performed and were stable .


he will need to follow up with dr. mckinney in 4 weeks for repeat head imaging and continue with dilantin for one month .


impression : no evidence of significant abnormality .


reason : follow up ct


glucose - 101 lactate - 2.9 * na+ - 142 k+ - 3.6 cl- - 102 tco2 - 26


17 yo male pedestrian who was struck by auto at unknown speed ; +loc .


skull fracture


indication : fracture . assess for alignment .


the lung apices are clear without pneumothorax .


you will need to conrtinue with your lovenox injections for at least 4-6 weeks as instructed by orthopedics


wbc - 16.0 * rbc - 4.89 hgb - 14.5 hct - 40.4 mcv - 83 mch - 29.7 mchc - 35.9 * rdw - 13.4


there is no shift of normally midline structures or hydrocephalus .

hydrocephalus
shift of normally midline structures


there is no significant prevertebral soft tissue swelling .


the pneumocephalus adjacent to the linear skull fracture appears to have decreased in size .

the linear skull fracture
pneumocephalus


2. oxycodone 5 mg tablet sig : two ( 2 ) tablet po q4h ( every 4 hours ) as needed for pain .


3. docusate sodium 100 mg capsule sig : one ( 1 ) capsule po bid ( 2 times a day ).


multiple posterior right - sided mastoid air cells are opacified with blood .


there is a non-displaced comminuted fracture of the proximal fibular diaphysis .


ct c-spine w/o contrast


there is a linear right temporal calvarial fracture extending into the right temporal bones .


1. phenytoin 50 mg tablet , chewable sig : two ( 2 ) tablet , chewable po three times a day for 1 months .


2015-10-27 open reduction and internal fixation of right tib/fib fractures


17 year old man with pneumocephalus s/p cmed ccu v. mvc


discussed with trauma team during the study .


additionally , a side plate is seen medially fixating the fracture .


right tibia / fibula , ap and lateral views : an intramedullary rod is seen fixating a proximal diaphyseal comminuted tibial fracture with six proximal and two distal screws .

six proximal and two distal screws
an intramedullary rod


allergic to pcn and sulfa


pt - 12.7 ptt - 23.8 inr(pt) - 1.1


there are persistent bifrontal and right parietal hemorrhagic contusions with surrounding edema and possible small left frontal subarachnoid hemorrhage ( adjacent to falx ) which are largely unchanged .


there is normal alignment of the cervical vertebral bodies without acute fracture or traumatic malalignment .


56 year old man with open rle fx now s/p fixation


indication : postoperative fever .


technique : axial mdct images of the cervical spine with coronal and sagittal reformats without iv contrast .


eval for fx


he was medflighted to the hospital for orthopedics for ongoing trauma care .


eval for alignment , post op changes


findings : the previously noted subdural hemorrhage in the right posterior fossa appears less conspicuous .


there is no shift of normally midline structures .


attention deficit disorder ( diagnosed @ 14 yrs of age )


urea n - 12 creat - 1.0


impression : linear right temporal calvarial fracture extending into the mastoid process with small associated right posterior convexity subdural hematoma and pneumocephalus .


2) linear right temporal calvarial fracture extending into the mastoid with a small right posterior convexity subdural hematoma and pneumocephalus ; see head ct report .


2. multifocal hemorrhagic contusions and surrounding edema are largely unchanged .

surrounding edema
multifocal hemorrhagic contusions


1. decreased size of right posterior subdural hemorrhage .


sulfa ( sulfonamides ) / penicillins


ct head w/o contrast


the air- fluid level in the right sphenoid sinus and bilateral opacification of the mastoid air cells are unchanged .


no other acute fractures are appreciated .


he was admitted to the trauma service . orthopedics and neurosurgery were consulted because of his injuries .


there is also a left occipital scalp contusion but no associated skull fracture .

a left occipital scalp contusion
associated skull fracture


technique : non-contrast head ct .


there is a small subdural hematoma with components of pneumocephalus tracking from the mastoid air cells .

pneumocephalus
a small subdural hematoma


right comminuted tibia / fibula fracture


17 year old man with post-op fever .


1) no acute cervical spine fracture .


there is no evidence of chf .


impression : comminuted proximal tibiofibular fractures status post orif of the tibia with an intramedullary rod and side plate .

an intramedullary rod and side plate
status post orif of the tibia


technique : axial mdct images of the brain without iv contrast .


reason : please r/o acute process .


there is surrounding soft tissue swelling .


4. magnesium hydroxide 400 mg / 5 ml suspension sig : thirty ( 30 ) ml po q6h ( every 6 hours ) as needed for constipation .


there are no pleural effusions or focal consolidations .


technique : pa and lateral views of the chest .


eval for bleed


no evidence of immediate hardware complication .


please r/o acute process .


5. lovenox 40 mg / 0.4 ml syringe sig : 0.4 ml 's subcutaneous once a day for 30 days .


comparison : non-contrast head ct from 2015-10-27 .


findings : there is a linear nondepressed right temporal calvarial fracture extending into the mastoid process .


prominent sutures in this young patient , the right calvarial suture extending into the right temporal bones appears more prominent than its counterpart on the left , however , does not appear to represent an acute fracture .

prominent sutures
the right calvarial suture


follow up ct scan .


asa - neg ethanol - neg acetmnphn - neg bnzodzpn - neg barbitrt - neg tricyclic - neg

barbitrt acetmnphn bnzodzpn asa ethanol tricyclic


ct head w/o contrast


clinical history : history of pneumocephalus status post pedestrian versus motor vehicle collision .


chest ( pa & lat )


plt count - 247


head injury to the occiput .


amylase - 44


follow up ct


tib / fib ( ap & lat ) soft tissue


reason : eval for alignment , post op changes


surgery


he will need to continue on lovenox injections for at least 4-6 weeks .


there is small amount of mucosal thickening in the sphenoid sinuses .


please see detailed operative note for more information about the procedure .


lungs clear to auscultation bilaterally .


patient needs to have labs every monday and thursday including a cbc , chem-10 , ast , alt , alkaline phosphatase , albumin , total bilirubin and prograf level need to be obtained .

alkaline phosphatase
a cbc
labs
albumin
alt
prograf level
chem-10
ast
total bilirubin


sclera mildly icteric .


the patient did go to operating room on 2014-04-04 and the patient had cadaveric liver transplant performed by dr. michael sanders .


general : patient is in no acute distress .


the patient received mmf 1 gram b.i.d. , flagyl 500 mg iv x1 .


lethargic , occasionally falling asleep .


the patient also received unasyn for 2 days , fluconazole , heparin , protonix , insulin , morphine , bactrim .

unasyn fluconazole insulin bactrim morphine heparin protonix


weight was 122.5 .


abdomen : positive bowel sounds , soft , nondistended , nontender .


nadolol 20 mg q. day .


ultrasound was performed on 2014-04-01 demonstrating severe portal hypertension with massive peri splenic varices and splenorenal shunt .

severe portal hypertension
massive peri splenic varices


on 2014-04-04 , the transplant service was consulted because the patient was possibly going to the operating room for transplant on 2014-04-04 .


the patient is to call 787-984-9608 if any fevers , chills , nausea and vomiting , abdominal pain , inability to take medications , inability to eat or drink .

chills
fevers
abdominal pain
vomiting
nausea
inability to eat or drink
inability to take medications


vital signs were stable .


all cultures have been unremarkable .


mother died of end stage renal disease .


patient is on insulin sliding scale with fixed dose .


urine culture and blood culture have been unremarkable on 2014-04-03 .


repeat hepato fungal flare .


cultures were obtained on 2014-03-31 .


on 2014-04-02 , the patient was awake , alert and oriented , taking lactulose .


family history : father died of metastatic colon cancer .


also , the patient has a past medical history of hypertension , glucose intolerance , peripheral neuropathy .

peripheral neuropathy
glucose intolerance
hypertension


lopressor 50 m b.i.d.


1+ edema bilaterally .


mmf 1000 mg b.i.d. .


total bilirubin was 0.9 .


denies any pain or discomfort .


prednisone 20 mg q. day .


ast 82 .


there was mild asterixis .


sodium of 138 ; potassium 3.5 ; 106 , 28 , 31 , 1.0 , glucose 134 .


bactrim ss 1 tab q. day .


on 2014-04-09 , fk level was 10.3 .


four bands were placed without difficulty .


egd on 2013-12-08 demonstrated 5 cores of varices , grade 1 to 2 at the lower third of the esophagus .


colace 100 mg b.i.d.


abdomen : slightly distended , nontender .


underwent treatment with interferon 10 years ago .


alt 176 .


alkaline phosphatase 78 which all have significantly decreased since postoperative day number 1 .


percocet 1 to 2 tabs q. 4 to 6 hours prn .


normal s1 and s2 without murmurs or rubs .


drains continued to put out significant amount of fluid .


lasix 20 mg b.i.d.


the patient is a 49 year-old man with hepatitis c cirrhosis complicated by encephalopathy , positive esophageal varices , now with worsening confusion and lethargy .

lethargy
worsening confusion
hepatitis c cirrhosis
positive esophageal varices
encephalopathy


7.1 , hematocrit of 30.8 , platelets 90 .


tacrolimus 3 mg b.i.d.


he gets cold easily but denies fevers .


patient continued on lactulose .


hcv cirrhosis .


a heparin independent antibody was sent off on 2014-04-07 which was unremarkable .


continue on rifaximine .


he denies any abdominal pain .


the patient has been compliant with his medications .


continue lasix .


obvious ascites .


valcyte 900 mg q. day .


he has had night sweats for the past 2 weeks .


the patient also reports that he has had " yellowish eyes , some shaking and his breath smelled more like ammonia over the past 3 days ."


no known drug allergies .


patient continued getting acyclovir , prednisone , mmf one gram b.i.d .


difficulty with word finding at times .


on postoperative day number 1 , duplex ultrasound of the patient 's liver was performed demonstrating normal appearing portal veins and hepatic arteries .


wife reports that the patient has a history of lethargy and confusion , similar to the symptoms for which the patient was recently admitted .


these findings may reflect thrombus within the left and right hepatic veins .


additionally , there is diminished color flow with confluence of the hepatic veins .


waltham-ludlow drains put out on the 13th 620 and 380 .


caval narrowing is seen , most likely correlation to clinical history is recommended and further evaluation of the ct or short-term ultrasounds for follow-up was recommended .


testosterone 4 mg q. 24 hours .


omalley was consulted on 2014-04-08 for better glucose control since the patient was on steroids .


retazepine 50 mg q h.s.


pathology demonstrates that the pathology results of the liver were not finalized .


the patient contracted hcv 20 years ago secondary to iv drug use .


patient 's labs from 2014-04-10 were the following :


the patient was on fk 2 and 2 that was started on postoperative day number 2 .


today , on 2014-03-03 , the patient was seen in clinic with increased lethargy , confusion .


the patient was on propofol for 2 days .


history of hepatic encephalopathy .


patient was transfused 1 unit of platelets on 2014-04-08 for platelet count of 66 .


patient was started on lactulose and rifaximine which improved his mental status .


alt 44 .


on 2014-04-04 , labs were as follows :


esophageal varices .


trazodone stopped .


insulin regular .


infectious work-up was negative .


the patient was taken off of neurontin because it started to worsen his mental status .


protonix 40 mg q. 24 .


lasix 40 mg q. day .


moltipine 5 mg q. day .


there appears to be a decreased and sluggish flow within the right and left hepatic veins with loss of normal respiratory variations , wave forms and the intrahepatic portion .


hepatitis viral load was 76,500 .


alkaline phosphatase 169 .


fluconazole 400 mg q. 24 hours .


wbc of 8.3 ; hematocrit of 30.6 ; platelets 69 ; sodium 132 ; 3.9 , 102 , 22 , serum creatinine of 13 and 1.1 .

serum creatinine
hematocrit
wbc
sodium
platelets


hepatitis c cirrhosis .


he stopped secondary to aggressive behavior .


ast 87 .


glucose 114 .


positive gynecomastia .


pt of 20.6 .


on 2014-04-09 , patient continued to do very well , ambulating , tolerating a diet , urinating without difficulty .


lactulose 30 mg q.i.d.


inr of 2.0 .


neck : no lad .


ptt of 38.7 .


the patient has been admitted 5 x in the past to nantucket cottage hospital since 11-30 for encephalopathy .


protonix 20 mg q. 24 hours .


liver transplant surgery service


amlodipine 5 mg q. day .


the feeney gann-burlington drain on postoperative day number demonstrated medial output of 780 with lateral output of 150 .


osamine 200 mg t.i.d.


cbc had a white blood cell count of 9 , 17 polys , 0 bands , platelets of 326 .

polys
a white blood cell count
bands
platelets
cbc


fetal screens , o positive , antibody negative , rpr nonreactive , rubella immune , hepatitis surface antigen negative , gbs unknown .

fetal screens
rubella
antibody
hepatitis surface antigen
gbs
rpr


caffeine citrate was initiated on 11-14 for apnea and bradycardia of prematurity .


ivf pregnancy complicated by iugr , 2 vessel cord , normal fetal echo reverse diastolic flow and demise of twin a at 27 weeks .

demise of twin a
2 vessel cord
ivf pregnancy
iugr


her most recent set of electrolytes were on 2015-11-13 with a sodium of 143 , a potassium of 6.3 hemolyzed , a chloride of 113 and a total co2 of 17 .

a sodium
a potassium
a chloride
a total co2


hyperbilirubinemia resolving .


she received 48 hours of ampicillin and gentamycin with negative blood cultures and antibiotics were discontinued .


apnea and bradycardia of prematurity .


heart ranges 130 s to 160 s.


she will need advance calorie density for better growth .


blood pressure most recently 60/37 with a mean of 44 .


abruption noted .


birth weight was 1670 grams 50 th percentile , length 43 cm 50 th percentile .


immunizations : recommended synagis rsv prophylaxis should be considered from november through march for infants who meet any of the following 3 criteria , born at less than 32 weeks , born between 32 and 35 weeks with 2 of the following , daycare during rsv season , a smoker in the household , neuromuscular disease and weight abnormalities or school age siblings with chronic lung disease .

weight abnormalities
neuromuscular disease
chronic lung disease


on admission weight 1670 grams approximately 50 th percentile , length 43 cm 50 th percentile , head circumference not done .


head circumference not done .


state newborn screen was sent on 2015-11-12 .


apgars were 6 and 9 .


sensory , hearing screen has not yet been performed , but should be done prior to discharge .


pprom with bleeding and transverse lie prompted cesarean section .


she remained on cpap for a total of 24 hours at which time she transitioned to room air and continues to be stable in room air .


influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age .


twin b with normal fetal survey was transferred to boston medical center at 26 and 2/7 weeks with iugr of twin a was first noted , presented with preterm labor at 31 weeks .


medications , continue caffeine citrate of 11 mg po every day .


rule out sepsis with antibiotic .


no hip click .


premature infant born at 31 and 6/7 weeks gestation , resolved respiratory distress syndrome .

premature infant
respiratory distress syndrome


no sacral dimple .


head ultrasound was performed on 2015-11-16 and was normal .


continue 150 cc per kilo per day of special care 20 calories advancing caloric intake as required to maintain weight gain of 3 grams per kilogram per day .


mother was on clindamycin since 11-04 .


car seat position screening has not yet been done .


before this age and for the first 24 months of the child 's life immunizations against influenza is recommended for household contacts and out of home care givers .


positive vaginal tag .


x-ray revealed mild respiratory distress syndrome .


immunizations received , infant has not received any immunizations to date .


no murmur .


betamethasone complete at approximately 26 weeks and 31 weeks .


no hepatosplenomegaly .


state newborn screen was sent on day of life #3 and at discharge .


most recent bilirubin was on 11-14 of 4.8 / 0.3 .


infant placed on cpap .


nondysmorphic intact veliz .


hematocrit on admission was 53.7 .


infant is under phototherapy , which was discontinued on 11-13 .


anterior fontanel soft , flat , cap and prong cpap in place .


infant was initially started on 80 cc per kilo per day of d10w .


a cbc and blood culture obtained on admission .


she is currently receiving 150 cc per kilo per day of special care 20 .


decrease tone , ruddy , warm , well perfused with peripheral iv in left hand .


infant achieved full enteral feedings by day of life 6 .


her discharge weight is 1477 gm .


enteral feedings were initiated on day of life #1 .


she has not required any blood transfusions .


gi . bilirubin peaked on day of life #2 of 9.0 / 0.3 .


mills was admitted to the newborn intensive care unit with moderate respiratory distress .


she was empirically started on vanco/zosyn for empiric hosp acquired pna coverage

vanco/zosyn
empiric hosp acquired pna coverage


there was still concern for her effusion contributing to her sob at the osh so she was transferred for drainage and treatment of chf .


the procedure team was called to consider doing a left thoracentesis , but she was declined because it was felt that her effusions were transudative , secondary to chf , and it was recommended to treat chf .


in the last 12 hours of her life , her pulsus was 12 , and she was felt to likely to have aspect of tamponade physiology , since her preload was reduced .


pt started on ctx 05-27 .


she denies any cp / cough / fever , abdominal pain / diarrhea , black or bloody stools or headache .

fever
diarrhea
abdominal pain
headache
cp
black or bloody stools
cough


the pt continued to have low urine output .


- see course of diuresis above .


#. afib/sss : she was a-paced , pacer placed 05-08 in dddr mode , complicated by ptx requiring chest tube which resolved and tube was removed during admit for pacer , no evidence of ptx on most recent cxr .

dddr mode
pacer
tube
pacer
chest tube
a-paced


- no transfusions , cmo/dnr/dni


#. id : initially had leukocytosis at admission , with chest ct showing possible underlying consolidations vs. atelectasis , levoflox started 05-24 and subsequently stopped ( no consolidations on cxr and afebrile ).

consolidations
atelectasis
underlying consolidations
leukocytosis
afebrile


as she was felt by the ccu to be a poor candidate for right heart cath , was hemodynamically stable with blood pressure 110 s- 120 s systolic and pulse 70 s- 80 s , she was called out of the ccu and back to the cardiac floor without intervention .

pulse
blood pressure
right heart cath
systolic


pt now on iv ceftriaxone ( was on levoflox since 05-24 however ua now floridly positive ( more so than ua at osh ) so felt possibly levo-resistant .


then , on 05-29 , she demonstrated bilateral pleural effusions ( reaccumulated ), right lower lobe infiltrate ( started on vanco / zosyn )-> put on face mask , given lasix x 1 bolus 100 mg , responded somewhat and o2 sat stable in low 90 s.

bilateral pleural effusions
right lower lobe infiltrate


since admission , she ruled out for mi by enzymes , and had a right sided thoracentesis which yielded transudative fluid .


we continued her albuterol / atrovent nebs , diuresis with iv lasix drip and boluses .

atrovent nebs
boluses
iv lasix drip
diuresis
her albuterol


she requested the patient be made comfort measures only .


she continued to put out low amounts of urine throughout the admission , despite aggressive diuresis with iv lasix gtt and boluses .

boluses
iv lasix gtt
aggressive diuresis


hypothyroidism


mary studies c/w transudate .


she was given a lasix drip iv upon call-out of the icu , and additional boluses of iv lasix , 200 mg then 300 mg iv were given with a good response , however , she remained net positive fluid balance .


wbc s since admission were as high as 14,000 but normalized .


renal consultants did not feel there was an emergent need for dialysis .


her 05-27 cxr post procedure w/o pnx , effusion much improved , yet her 05-28 cxr worse than 05-27 with some reaccumulation of right pleural effusion .


ecg : a paced at 70 bpm / nml axis , lbbb , no st or tw changes


heent : mmm , jvp at 14 cm , no bruits , supple


renal consultants did not feel that there was an indication for urgent hemodialysis .


#. sob : most consistent with chf by exam , although unknown what the severity of her copd is currently .


no hydronephrosis is seen .


we started her on dilt for additional a fib control ( revert back to a fib on 05-29 ), which was stopped when the pt was made cmo .


aranesp 100 mcg ( x1 05-26 )


she has been gently diuresed but has worsening arf .


ct chest at erich lindemann mental health center 05-25 : large pericardial effusion , bilat pleural eff with underlying consolidation which could represent pna vs. atelectasis

atelectasis
pna
bilat pleural eff
underlying consolidation
large pericardial effusion


#. oliguric arf : likely prerenal due to n/v poor po intake and poor forward flow , however , need to continue diuresis .

n/v
poor forward flow
poor po intake
oliguric arf


lung volumes are low .


her urine lytes consistent with atn , fena 4% .


82 y/o f w h/o afib , sss s/p pacer 05-08 c/b ptx requiring ct , cad , who was readmitted 05-24 with arf and lethargy , found to have a large pericardial effusion and bilateral pleural effusions , with echo showing no evidence of tamponade , who is transferred for possible pericardial effusion drainage and treatment of chf , as well as drainage of bilateral pleural effusions .

bilateral pleural effusions
sss
afib
cad
bilateral pleural effusions
a large pericardial effusion
arf
lethargy
chf
tamponade
ptx

drainage
pericardial effusion drainage
treatment
pacer
ct


she also had 2 echocardiograms which revealed persistent pericardial effusions .


levothyroxine 50 mcg daily


it was felt that given her age , multiple co-morbidities , that her prognosis was poor even prior to ccu admission , possible pericardial drainage or repeat thoracenteses .

repeat thoracenteses
pericardial drainage


she was admitted to cambridge hospital 2018-05-24 with arf ( cr 3.5 up from 0.9 ) and sob .


copd


it was felt posthumously that her large pericardial effusion was most likely secondary to a complication of pacer placement , although this was not seen on imaging .

a complication
her large pericardial effusion


her o2 requirement has increased despite diuresis .


#. pericardial effusion : unclear etiology , osh had raised question of rv perforation from pacer , however she had a normal echo appearance of lead , no tamponade by exam .

tamponade
pericardial effusion
rv perforation


tte at erich lindemann mental health center 05-26 : mod-lg circumferential pericardial eff , no evidence of rv diastolic collapse , no mv inflow evidence of tamponade , pacer lead located in rv apex

rv diastolic collapse
mod-lg circumferential pericardial eff
tamponade


we continued amiodarone until pt was made cmo .


gerd


pt is now s/p drainage of right pleural effusion , diagnostic and therapeutic , with studies consistent with transudate , etiology most likely 02-15 chf .


according to her guardian she was discharged to her nh for a few days after her pacer was placed 05-08 , which was complicated by a ptx requiring ct placement which had been d/c 'd in the hospital after resolution of her ptx .


tte revealed large pericardial effusion .


legally blind


she was guiaic negative .


she underwent a tte at erich lindemann mental health center today ( 05-26 ) showing mod-lg circumferential pericardial effusion without evidence of rv diastolic collapse and no mv inflow evidence of tamponade , pacer wire located in rv apex .


codeine / iodine


anticoagulation has not been given this admission .


amiodarone 200 mg daily


1. pulmonary edema and hypoxic respiratory failure

hypoxic respiratory failure
pulmonary edema


7. coronary artery disease


mild pulmonary edema is unchanged .


6. sick sinus syndrome status post pacer placement


abd : s/nt/slightly distended , dec bs , no cva tenderness


5. paroxysmal atrial fibrillation


ext : 1+ le edema


4. congestive heart failure


in the setting of her ongoing pericardial effusion , she was transferred for closer observation to the ccu .


3. moderate bilateral pleural effusions


impression : no evidence of hydronephrosis .


82 f with h/o copd , cad , pafib and sss s/p pacer on 05-08 for symptomatic pauses is transferred for large pericardial effusion ? needing drainage and chf .

pafib
sss
cad
copd
symptomatic pauses
large pericardial effusion
chf


2. large pericardial effusion


the ccu fellow and team declined to do pericardial drainage , as the pt was hemodynamically stable , without change in appearance of effusion by echo performed at bedside by cards fellow .


albuterol-ipratroprium inh 2 sprays tid prn


diovan 160 mg daily


odell does not believe the pt would want to be intubated , with central line , right heart cath , in the ccu .


imdur 60 mg daily


her lasix gtt continued during this time .


pepcid 20 mg daily


the pt will be made comfortable , with goals of care shifted towards suppressing her air hunger and pain .


levofloxacin 250 mg iv daily ( started 05-24 )


ec asa 81 mg daily


diltiazem cd 240 mg


pacer seen in rv apex , but cannot exclude perforation .


the bladder appears unremarkable and contains a foley catheter .


paxil 20 mg daily


head ct at erich lindemann mental health center 05-24 : atrophy , dense calcification of the tentorium , most likely of metabolic etiology

atrophy
dense calcification of the tentorium


renal u/s negative for hydronephrosis .


#. access : piv


she was afebrile .


on call out from the ccu , the pt was satting 93% on 4-5l nc , and through the following night , her oxygen requirement increased to nrb , wherein she was satting upper 80 s- low 90 s.


at erich lindemann mental health center she was discovered to have arf , a large pericardial effusion , and bilateral pleural effusions .

bilateral pleural effusions
arf
a large pericardial effusion


the morning of 5/17 , her pulsus parodoxicus was 12 .


u/a on 05-27 c/w uti .


vancomycin and zosyn were started .


she was treated with ivf for her arf .


because of her abg , and declining clinical status , the ccu was notified for possible transfer .


- possible opacity on cxr - along w/ leukocytosis .


echo 2018-05-28


explained to lewin that pt will likely need to be intubated , as she cannot lie flat , and most likely cannot undergo pericardial drainage , thoracentesis , or right heart cath with bipap ( which would have been the next measure after nrb , and prior to intubation ).

thoracentesis
pericardial drainage
nrb
bipap
right heart cath
intubation


cva


a cxr was performed the evening of 5/16 , showing moderate sized bilateral pleural effusions , stable cardiomegaly and a possible rll infiltrate .


#. pleural effusions : likely due to chf although had some leukocytosis at admission to osh .


large pericardial effusion , transfer from osh


she denies any cp / cough / fever / abd pain / diarrhea / black or bloody stools / headache .

any cp
diarrhea
black or bloody stools
headache
cough
fever
abd pain


she had some nausea / vomiting and generally was taking poor pos at her nh .


there had been some concern her nausea was due to her amiodarone which had been discontinued about 1 week ago .


detrol la 4 mg daily


imaging at providence behavioral health hospital :


cxr at erich lindemann mental health center 05-26 : bilateral pleural eff and pericardial eff


abg that evening was 7.29/51/56 on 4l nc and early the next morning , was 7.25/62/64 on nrb .


she was then sent to franklin medical center 05-24 with lethargy and n/v .


impression : unchanged moderate bilateral pleural effusions and mild chf .


#. anemia : unclear source .


afib , sss


- after she was made cmo , the pt was started on morphine gtt to maximize comfort and minimize air hunger .


bibasilar atelectasis is unchanged .


findings : the lung volumes are moderate bilateral pleural effusions are unchanged .


- we continued asa / imdur / ccb / hold diovan until pt was made cmo .


cad


her pacer wires in correct position .


no urinary calculi are seen .


findings : the right kidney measures 11 cm in length , the left kidney measures 9.7 cm in length .


pacer dddr ( vitatron cl860 ) placed 05-08 for sss with symptomatic bradycardia , c/b r ptx requiring chest tube

pacer dddr ( vitatron cl860 )
chest tube


renal us 2018-05-28


this has still be known to occur during the placement of pacemaker .


pulm : no bs 01-15 way up bilat , no consolidation


pulsus parodoxus = 6-8 mm


#. chf : normal ef on tte so possibly with diastolic dysfunction , ruled out for mi


impression : moderate to large pericardial effusion ( minimal fluid anteriorly ( 1cm ), ? bloody ).

moderate to large pericardial effusion
minimal fluid anteriorly
bloody


htn


a nitro drip was started in an effort to decrease her preload and afterload .


her urine output decreased to nearly zero .


exam : t 96.2 hr 70 bp 118/46 r 24 sat 90% on 60%fm


today she only complains of some sob , which she says remains largely unchanged over the past few days .


#. fen : check lytes , most recently normal .


she was given 200 mg iv lasix x 1 with an additional 100 cc of urine output the evening of 5/16 .


her oxygen sats did not improve .


no definite tamponade physiology .


she had a bnp of > 5000 on admission .


cardiac/renal diet


explained that despite these invasive measures , she still has a very poor prognosis .


thoracentesis 2018-05-27


cxr 2018-05-30


gen : mild resp distress speaking in full sentences but using accessory muscles


cxr revealed evidence of cardiomegaly and pulm edema .


1. lisinopril 20 mg daily


you were treated with medications to improve your blood pressure .


he was treated w/ asa 325 mg , lasix 10 mg iv , and hydralazine 10 mg iv x 2 .


an echo performed on admission showed an lf ef of 25% .


ext : warm , 2+ dp b/l , 2+ pitting edema to knees b/l


46 - yo-man w/ active cocaine use presents w/ le edema .


you came in with hypertensive emergency .


if clinically indicated a tee would be better able to define an abnormality of the aortic valve .


sclera anicteric .


dyspnea


- lower extremity edema improved


- mild transaminitis likely 03-25 etoh and cocaine abuse


cv : reg s1 , loud s2 , + 2/6 systolic murmur radiating to axilla , no s3/s4/r

s3/s4/r
2/6 systolic murmur radiating to axilla
loud s2


- arf


there is no family history of premature coronary artery disease or sudden death .

premature coronary artery disease
sudden death


renal failure : creatinine on admission was 1.6 likely acute hypertensive nephropathy plus probalbe long-standing hypertensive disease .

acute hypertensive nephropathy
long-standing hypertensive disease
renal failure


- hypertensive emergency


ekg demonstrated nsr at 87 bpm , nl axis , nl int , lvh w/ strain pattern , no ischemic changes .


4. lisinopril 20 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


mild ( 1+ ) mitral regurgitation is seen .


cxr :


3. labetalol 200 mg tablet sig : two ( 2 ) tablet po bid ( 2 times a day ).


2. hydrochlorothiazide 25 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


1. aspirin 325 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


it is hoped with good blood pressure control and use of an ace-i with follow up in addition to cocaine abstaining will improved his cardiac function .


the aortic valve leaflets ( 3 ) are minimally thickened .


he responded well to lasix w/ good uop , but diastolic bp remained elevated at 170 , prompting initiation of nitroprusside gtt .


please return to the deanna if you experience sob , chest pain , fevers , chills , dizziness , decreased urine output .

sob
chest pain
chills
fevers
dizziness
decreased urine output


alt(sgpt) - 77 * ast(sgot) - 60 * ck(cpk) - 195 * alk phos - 104 amylase - 100 tot bili - 0.4

ast(sgot)
amylase
alk phos
tot bili
alt(sgpt)
ck(cpk)


his lower extremity edema improved with diuresis .


no signs of end-organ damage at present except for elevated creatinine , which is more likely a chronic problem .

end-organ damage
elevated creatinine
a chronic problem


very small circumferential pericardial effusion .


moderate to severe enlargement of the cardiac silhouette , and particularly the left atrium accompanied by pulmonary vascular congestion and mild pulmonary edema consistent with heart failure .


there is no mitral valve prolapse .


drinks 3-4 beers a few times weekly , no h/o withdrawal symptoms , seizures or dt s.


moderate pulmonary arterial hypertension .


tissue doppler imaging suggests an increased left ventricular filling pressure ( pcwp > 18 mmhg ).


his blood pressure was taken down from 230 systolic to approx 160 systolic / 100 diastolic on discharge .

systolic
systolic
diastolic
his blood pressure


the right ventricular cavity is mildly dilated with severe free wall hypokinesis .

severe free wall hypokinesis
mildly dilated


hypertensive urgency :


there is moderate symmetric left ventricular hypertrophy with mild cavity dilation and severe global hypokinesis .


no left ventricular thrombus is seen .


gen : lying flat in bed , pleasant and conversational , nad


impression : moderate symmetric eft ventricular hypertrophy with severe global biventricular hypokinesis c/w diffuse process ( toxin , metabolic , cannot exclude myocarditis ; in the absence of lvh on ecg , an infiltrative process should also be considered ).


46 - yo-man w/ cocaine abuse presents w/ le edema and doe likely from diastolic heart failure in the setting of cocaine use complicated by hypertensive urgency .

le edema
doe
diastolic heart failure
hypertensive urgency


penicillins


bp 230/170 on presentation , most likely from chronic htn exacerbated by cocaine use .


the patient was started on labetalol and lisinopril .


the left atrium is moderately dilated .


ck-mb - 4 probnp - 7489 *


three days ago , he developed dyspnea on exertion when climbing stairs , assoc w/ 2-pillow orthopnea and pnd .


there is a very small circumferential pericardial effusion .


he denies any recent chest pain , palpitations , headache , confusion , weakness , numbness , abd pain , or hematuria .

any recent chest pain
palpitations
weakness
numbness
headache
confusion
hematuria
abd pain


there is moderate pulmonary artery systolic hypertension .


10 days ago , he developed b/l le edema that has gotten progressively worse until now .


wbc - 7.7 rbc - 5.00 hgb - 15.0 hct - 42.8 mcv - 86 mch - 30.0 mchc - 35.0 rdw - 14.6


today , his wife convinced him to present to the deanna for evaluation .


discharged on ace-i .


plt count - 315


possible abnormality on the aortic valve as described above without aortic regurgitation .

aortic regurgitation
abnormality on the aortic valve


bnp was elevated at 7500 .


vs : t, bp 181/122 , hr 84 , rr 12 , o2 98% 2l/m


mild mitral regurgitation .


ctropnt - 0.02 *


in the deanna , his bp was 230/170 .


no recent viral syndromes or uri s.


2. hctz 25 mg daily


heent : ncat .


abd : obese , +bs , soft , ntnd .


3. labetalol 400 mg bid


4. asa 162mg daily


neck : supple with jvp of 8 cm .


it is extremely important for you to take these medications .


no aortic stenosis or aortic regurgitation is seen .


pulm : cta b/l w/ no crackles or wheezing


chest : mild intercostal and sternal retractions .


waltham was monitored for 90 minutes without any episodes of apnea or oxygen desaturation .


blood type a positive , antibody negative , rubella immune , rpr nonreactive , hepatitis b surface antigen negative , group beta strep status unknown .

rubella
antibody
rpr
hepatitis b surface antigen
group beta strep status
blood type


3. car seat position screening was performed .


discharge weight is 1.89 kg .


beverly was initially npo and maintained on intravenous fluids .


2. medications : ferrous sulfate 0.15 cc po q day 25 mg / ml dilution .


4. gastrointestinal : boston required treatment for unconjungated hyperbilirubinemia with phototherapy .


general : nondysmorphic preterm male in mild respiratory distress .


ken nansteel-miller is the triplet #3 of a spontaneous triamniotic-trichorionic triplet pregnancy born to a 39-year-old g4 p1 spontaneous abortion 2 woman .


she was treated with bed rest and prn terbutaline .


he received phototherapy for approximately 72 hours .


rebound bilirubin on day of life #7 was 6.6 , and total was 0.2 direct .


femoral pulses +2 .


plan is to receive hepatitis b in the pediatrician 's office , once he reaches a weight of 2 kg .


no murmurs have been noted .


influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age .


cardiovascular : regular , rate , and rhythm , no murmur .


6. immunizations recommended : synagis rsv prophylaxis should be considered from october through april for infants who meet any of the following three criteria :


3) with chronic lung disease .


1. prematurity at 34 weeks gestation .


5. no immunizations administered .


breath sounds equal with fair aeration .


4. state newborn screens were sent on 09-27 and 2011-10-05 with no notification of abnormal results to date .


before this age , the family and other caregivers should be considered for immunization against influenza to protect the infant .


weight 1.7 kg , length 41.5 cm , head circumference 29 cm , all 10th-25th percentile for 34 weeks .


positive red reflex bilaterally .


3. unconjugated hyperbilirubinemia .


2. cardiovascular : falmouth has maintained normal heart rates and blood pressures .


1. respiratory : lincoln required nasal cannula o2 for approximately the first 8-12 hours of life .


he was admitted to the neonatal intensive care unit for treatment of prematurity .


his peak serum bilirubin occurred on day of life three with a total of 8.3 / 0.2 direct , 8.1 indirect mg/dl .


she was admitted on 2011-08-25 for nausea , vomiting , and a shortened cervix .


the mother was followed closely and received betamethasone 2011-08-22 .


he has had no episodes of spontaneous apnea during admission .


throughout admission , there are no neurological concerns at the time of discharge .


other medications including prozac .


this triplet #3 emerged with spontaneous respirations , and required blow-by oxygen in the delivery room .


abdomen is soft , nontender , nondistended , no masses , positive bowel sounds .


the babies were born by elective cesarean section at 34 weeks gestation .


apgars were seven at one minute and eight at five minutes .


enteral feeds were started on day of life #1 , and gradually advanced to full volume .


audiology : hearing screening was performed with automated auditory brain stem responses .


distant heart sounds , rrr


10-01 cabg x 3


5. oxycodone - acetaminophen 5-325 mg tablet sig : 1-2 tablets po every 4-6 hours as needed for pain .


60 yo m with exertional angina -> positive ett -> cath with severe 3vd

severe 3vd
positive ett
exertional angina


8. glipizide 5 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ).


2019-10-07 05:30 am blood glucose - 156 * urean - 20 creat - 1.0 na - 140 k - 3.8 cl - 99 hco3 - 31 angap - 14

na hco3 k creat urean cl glucose blood angap


2019-10-07 05:30 am blood wbc - 6.5 rbc - 3.23 * hgb - 9.5 * hct - 27.6 * mcv - 86 mch - 29.4 mchc - 34.4 rdw - 14.0 plt ct - 356 #

plt ct
mch
mcv
rdw
mchc
rbc
wbc
hct
blood
hgb


4. docusate sodium 150 mg / 15 ml liquid sig : one ( 1 ) po bid ( 2 times a day ).


6. clopidogrel 75 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


? tia


lisinopril , protonix , glipizide , metformin , asa

metformin asa lisinopril protonix glipizide


1. aspirin 81 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po daily ( daily ).


7. atorvastatin 10 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


urinary incontinence


3. metoprolol tartrate 50 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ).


extrem warm , no edema , no varicosities , 2+ pedal pulses


he was seen by speech and swallowing who recommended npo , he then underwent a video swallow after which he was changed to a diet of thin liquids and soft solids , and felt that his eeating may be limited by his loose teeth .

a diet of thin liquids and soft solids
npo


patient recorded as having no known allergies to drugs


9. lisinopril 10 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


exertional angina


he was taken to the operating room on 2019-10-01 where he underwent a cabg x 3 .


nad 76 184/87 18


he was weaned from his vasoactive drips and transferred to the floor on pod #2 .


dm


call with fever , redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week .

weight gain
drainage from incision
redness
fever


2019-10-07 05:30 am blood plt ct - 356 #


shower , no baths , no lotions , creams or powders to incisions .


cad


father with ? mi at unknown age


2019-10-04 06:50 am blood pt - 13.2 * ptt - 32.1 inr(pt) - 1.2 *


teeth in poor repair


cataracts s/p removal c/b enucleated left cmed csru


urinary incontinence


10. hydrochlorothiazide 25 mg tablet sig : one ( 1 ) tablet po once a day .


cataracts s/p removal of in mayotte c/b enucleated cmed csru


htn


2. pantoprazole 40 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po q24h ( every 24 hours ).


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


the patient presented with a chief complaint of found down .


your patient was admitted under the care of reefraup , ja y with a preliminary diagnosis of syncope .


1. coronary artery disease : the patient was taken to cardiac catheterization where she was found to have two vessel disease .

two vessel disease
coronary artery disease


2. lisinopril 5 q.d.


she will follow-up with dr. welch with an echocardiogram on 2015-07-24 in a meeting to discuss risk stratification for sudden cardiac death and possible icd placement .


4. coumadin 5 q.d.


the patient was already on an aspirin and plavix should this represent a small stroke .


the patient had no evidence for weakness on examination with good proximal and distal strength in the lower extremities as well as intact sensation .


3. toprol xl 100 q.d.


she reports that it had essentially started earlier in the day with some gerd-like symptoms .


laboratory and radiologic data : on admission , white count 10.8 , hematocrit 38.2 , platelets 324,000 .


6. lovenox 60 mg b.i.d. until therapeutic on coumadin .


5. plavix 75 q.d.


4. neurology : the patient complained of left lower extremity weakness with ambulation two days after her cardiac catheterization .


5. hematology : the patient was discharged on coumadin for apical akinesis and stroke risk .


the dorsalis pedis pulses were 2+ bilaterally .


extremities : there was no edema in the extremities .


follow-up plans : the patient will follow-up with her primary care physician in the week following discharge for further monitoring of her inr and adjustment of her coumadin dose .


she reports that the pain shot through her back .


abdomen : soft , nontender , nondistended , good bowel sounds .


discharge diagnosis : st elevation myocardial infarction , status post left anterior descending artery stent .


she was also able to ascend stairs without difficulty .


1. aspirin 325 q.d.


this will be further monitored by her primary care physician , dr. banks , who will adjust her coumadin dose .


general : the patient was a well appearing female in no acute distress .


she was found to have an ejection fraction of 30-35% as well as an akinetic apex and apical mid and septal akinesis .

an akinetic apex
apical mid and septal akinesis


no murmurs were appreciated .


lungs : clear to auscultation bilaterally .


on discharge , the patient was given lovenox injections which should be continued until the patient reaches a therapeutic dose of coumadin .


on admission , the patient was afebrile , blood pressure 146/88 , pulse 71 , respirations 18 .


the patient had an ep evaluation and will be followed-up by dr. welch .


3. rhythm : the patient was monitored on telemetry throughout her hospitalization with no significant events .


14-087 , the patient had a signal-averaged ekg .


3. uniretic 15/25 .


allergies : the patient has no known drug allergies .


5. gerd .


1. atenolol 25 .


however , there was no evidence for neurologic deficit on examination and this will be followed-up by her primary care physician .


2. crestor 10 q.d.


given the fact that the patient had significant apical akinesis , she was started on heparin with a transition to coumadin for anticoagulation for stroke prevention in the setting of apical akinesis .

significant apical akinesis
apical akinesis

coumadin
heparin
stroke prevention
anticoagulation


1. hypertension .


the patient was found to have 5057 e. sixth blvd. elevations in i , avl , and v1 through v2 and st depressions in ii , iii , and avf .


4. carpal tunnel syndrome .


the patient also had proximal rca lesion of 80% and a mid rca lesion of 80-90% which were not intervened upon .

proximal rca lesion of 80%
a mid rca lesion of 80-90%


3. chondrocalcinosis .


the patient was given an aspirin and plavix and in addition started on a beta elmore , maxine ace inhibitor , and these were titrated up as her blood pressure tolerated .

an aspirin
plavix
maxine ace inhibitor
a beta elmore


2. hypercholesterolemia .


the patient had twin lad stents to the lad diagonal and lad septal branches with taxus stents .


a tp3a inhibitor was not given for concern for dissection .


in the emergency room , the patient was given lopressor , nitroglycerin , and aspirin .


given the fact that the patient had issues with muscle cramping with atorvastatin in the past , she was started on pravastatin which should give less of these side effects .


the patient is a 57 - year-old female with a history of hypertension and hypercholesterolemia but no prior coronary artery disease history who presented with chest pain .

prior coronary artery disease history
chest pain
hypertension
hypercholesterolemia


the patient will follow-up with cardiology in one months time for further management of her coronary artery disease and further evaluation of her remaining rca lesions .

her coronary artery disease
her remaining rca lesions


the pain was intermittent through the day and then at 4:00 p.m. increased and was also associated with nausea and diaphoresis .


in addition to this , the patient will follow-up with cardiology , dr. foster , and dr. upshaw , on 2015-07-06 for further monitoring .


at that time , the pain was unremitting .


the patient has never had these symptoms in the past .


she had taken maalox but had no relief with this .


the proximal lad was found to have a 90% lesion with a septal branch with a 95% stenosis and a diagonal branch with 99% stenosis .

a 90% lesion
a 95% stenosis
99% stenosis


7. pravastatin 80 q.d.


2. pump : the patient had an echocardiogram to assess her lv function .


the patient reports the pain began at 4:00 p.m. on the day of admission .


the mother had received a complete course of betamethasone prior to delivery .


the birth length was 44 centimeters , the 75th percentile and the birth head circumference was 30.6 centimeters , in the 65th percentile

the birth length
the birth head circumference


she has been taking from 130 to 160 cc. per kilo per day on an ad lib feeding plan .


this infant emerged with apgars of 8 at one minute and 8 at five minutes .


mother is a 37 year old gravida 1 , para 0 now 2 woman whose blood type is a negative , antibody negative , rubella immune , rpr nonreactive , hepatitis b surface antigen negative and group b streptococcus unknown .

antibody
rubella
rpr
hepatitis b surface antigen
group b streptococcus
blood type


at the time of discharge , her weight is 2,200 grams ; her length is 49.5 centimeters ( 19.5 inches ) and her head circumference is 30.5 centimeters .

her weight
her length
her head circumference


the antibiotics were discontinued after 48 hours when the infant was clinically well and the blood cultures remained negative .


she had a head ultrasound on 2013-05-02 , that was completely within normal limits .


the birth weight was 1,980 grams , 80th percentile .


this pregnancy was achieved with in bartley fertilization .


cesarean section was performed under spinal anesthesia .


the infant was started on ampicillin and gentamycin at the time of admission for sepsis risk factor .


she started on enteral feeds on day of life number two and progressed without difficulty to full volume feedings by day of life five and then was advanced to calorie enhanced breast milk of 24 calories per ounce .

enteral feeds
full volume feedings
calorie enhanced breast milk


a cerclage was placed at 18 weeks gestation .


she has never received any blood products during this cmed csru stay .


she is receiving supplemental iron to provide 2 mg per kilo per day as elemental iron .


her peak bilirubin occurred on day of life five and was total 12.1 , direct 0.3 ; the last bilirubin on day of life six was total 11.1 , direct 0.4 .

total
total
direct
direct
her peak bilirubin
the last bilirubin


her hematocrit at the time of admission was 45.4 , platelets were 360,000 .


she never required phototherapy .


the infant is on breast milk with enfamil powder to provide 24 calories per ounce and on an ad lib feeding schedule .

an ad lib feeding schedule
breast milk with enfamil powder


2) influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they reach six months of age .


on admission , revealed a vigorous non-dysmorphic premature infant , with moderate subcostal retractions and some occasional grunting , normal s1 , s2 heart sounds , no murmur .

some occasional grunting
moderate subcostal retractions
murmur


the infant was intubated soon after admission to the cmed csru and received two doses of surfactant .


smoker in the household , with preschool siblings , or with chronic lung disease ;


5. the infant received the hepatitis b vaccine on 2013-05-09 , and synagis on 2013-05-11 .


1. prematurity at 31-6/7 weeks gestation .


4. state screens were sent on 04-27 and 2013-05-08 .


ferinsol 0.2 cc. to provide 5 mg a day .


richard williams , twin number ii , was born at 31-6/7 weeks gestation by cesarean section for rupture of membranes of twin number i and progressive preterm labor .

rupture of membranes
progressive preterm labor


her lung sounds are clear and equal .


she has a normal s1 , s2 heart sound and no murmur .


4. status post respiratory distress syndrome .


1) synagis rsv prophylaxis should be considered from october through april for infants who meet any of the following three criteria :


she has had no apnea , bradycardia or desaturation .


3. sepsis , ruled out .


her respirations are comfortable .


before this age , the family and other care givers should be considered for immunization against influenza to protect the infant .


3. the infant passed a car seat positioning test on 2013-05-11 .


2015-12-03 10:27 pm wbc - 8.4 rbc - 2.98 * hgb - 9.3 * hct - 26.3 * mcv - 88 mch - 31.1 mchc - 35.3 * rdw - 14.4


2015-12-03 10:27 pm glucose - 88 urea n - 12 creat - 1.0 sodium - 138 potassium - 3.3 chloride - 107 total co2 - 25 anion gap - 9

creat
urea n
glucose
chloride
total co2
sodium
potassium
anion gap


no edema , no clubbing


rrr s1/s2 no m


t 97.4 bp 100/62 p 56 rr 16


55 year old man with history of metastatic bladder cancer and recurrent dvt s on lovenox admitted with lower gi bleeding .

metastatic bladder cancer
recurrent dvt s
lower gi bleeding


patient recorded as having no known allergies to drugs


metastatic bladder ca now in remission s/p chemo/xrt s/p cystectomy and ileal loop urinary diversion and also radical prstatectomy with bilateral pelvic lymph node dissection .

bilateral pelvic lymph node dissection
radical prstatectomy
cystectomy
ileal loop urinary diversion
chemo/xrt


on ct scan , a right psoas mass , most consistent with a hematoma , was seen .


a ct scan of your abdomen showed a right pelvic mass , most likely a hematoma , which had been described previously in 2015-03-28 .


pt feeling well , denies abd pain , n/v , lh , sob , cp .


please continue to take your other medications as prescribed .


cbc , creatinine


gib


seen by gi and plan is to continue holding anticoagulation and repeat scope on monday .


the bleeding has stopped and you have remained hemodynamically stable and your hematocrit is stable , but you are at risk of bleeding from this source again with anticoagulation .


55 yo m w/ h/o recurrent bladder ca s/p cystectomy w/ ileal conduit p/w brbpr to osh .


h/o dvt s


b/l dvt s, most recent seen in ivc to right femoral vein s/p ivc filter 2015-01-15


attempts to visualize colon by conventional and ct virtual colonoscopy failed because of sigmoid angulation and inadequate preparation , respectively .


please see a doctor if you feel dizzy , or have blood in your stool again .


yellowish urine in rlq


please go to dr. colombo office later this week to have your labs drawn and sent to dr. powell .


denies fh of bleeding or clotting disorders .


also , a repeat outpatient ct colonoscopy with better preparation should be considered .


tagged rbc + activity in rlq .


lovenox was held until follow-up with primary care doctor .


1. pantoprazole 40 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po once a day .


lovenox 0.6 mg / kg sc bid


nephrolithiasis .


bright red blood per rectum


since the hematocrit of the patient was stable and outside records from 2015-03-28 mentioned a mass in the right pelvis , the patient was discharged .


anemia - baseline mid 30 s.


soft , +bs , nt , midline surgical scar , nephrostomy bag draining


we recommend that you do not resume your lovenox until talking to your pcp , dr. jessie .


metastatic , recurrent bladder cancer


virtual colonoscopy


you likely have a bleeding source in your colon that we have been unable to visualize .


colonoscopy


cscope unable to complete due to blood but tics seen .


right lower quadrant source of bleed on red blood cell scan .


2015-12-03 10:27 pm calcium - 8.7 phosphate - 2.4 * magnesium - 1.5 *


hct dropped 34 -> 22 .


transferred to mediplex rehab hospital icu where hct has remained stable .


egd normal .


2015-12-03 10:27 pm plt count - 164


2015-12-03 10:27 pm estgfr - using this


supple , no lad


2015-12-03 10:27 pm pt - 11.4 ptt - 27.5 inr(pt) - 1.0


sclera anicteric , mmm


mid aged man in nad


in general the patient was in no acute distress , afebrile , vital signs stable .


3. carotid disease .


1. lasix 20 mg p.o. q. 12 .


4. plavix 75 mg p.o. q.d. which has been discontinued prior to surgery .


2. potassium 20 meq p.o. q. 12 .


they requested that he follow up in three to five weeks for endurance training , however then physical therapy followed him a number of times afterward and decided that he was in good condition and did not need further physical therapy .


carotids were 1+ bilaterally .


6. lopressor 12.5 mg p.o. b.i.d.


abdomen : positive bowel sounds , soft , nontender , nondistended , no masses , no hepatosplenomegaly .

hepatosplenomegaly masses nondistended nontender


left main coronary artery was narrowed 50-60% , left anterior descending coronary artery 70% proximally , right coronary artery dominant diseased up to 90% proximally in the midportion , 70% distally .

right coronary artery dominant diseased
narrowed


this is a 67 - year-old male with a history of high cholesterol who was in his usual state of health until 2016-04-03 .


he may observe regular activity although he should avoid strenuous activity and should not drive while on pain medications .


1. history of high cholesterol .


his troponin was 20 and he had ekg changes .


3. colace 100 mg p.o. b.i.d.


positive for coronary artery disease .


his wife gave him mouth-to-mouth resuscitation and he regained consciousness .


5. percocet 1-2 tablets p.o. q. 4 p.r.n. pain .


heent : normocephalic , atraumatic .


extremities : without cyanosis , clubbing or edema .


2. aspirin 325 mg p.o. q.d.


neck : supple with full range of motion , no lymphadenopathy nor thyromegaly .


3. lopressor 25 mg p.o. b.i.d.


pulses were 2+ bilaterally throughout .


4. aspirin 325 mg p.o. q.d.


2. hemorrhoidectomy .


1. lipitor 20 mg p.o. q.d.


the patient was admitted to the hospital and on 2016-04-06 the patient underwent coronary artery bypass grafting x 4 with left internal mammary artery to the left anterior descending coronary artery , saphenous vein graft to the diagonal , saphenous vein graft to obtuse marginal , saphenous vein graft to right coronary artery , posterior descending coronary artery .


he presented to an outside hospital with an acute inferior myocardial infarction and was treated with thrombolytic therapy .


he underwent catheterization on 2016-04-05 which revealed a left ventricular ejection fraction of 50% , no mitral regurgitation , insufficiency or hypokinesis .

mitral regurgitation
insufficiency
hypokinesis

a left ventricular ejection fraction
catheterization


cardiovascular : regular rate and rhythm , no murmurs .


lungs : clear to auscultation bilaterally .


he was raking leaves on 04-02 and then developed episodes of mid chest pain and burning which radiated to the left arm .


positive right carotid bruits .


that night he reportedly stopped breathing and was unresponsive .


the patient appeared to have tolerated the procedure and was transferred to the cardiac intensive care unit for postoperative management .


he was started on beta blockers .


the patient had pacing wires and chest tubes in place , both of which over the course of his stay were removed successfully .


cardiothoracic surgery


lungs were clear to auscultation and equal .


hepatitis b surface antigen negative , rubella immune .


medications are tri-vi-michael 1 cc by mouth each day .


a blood culture was obtained upon admission and ampicillin and gentamicin were given for 48 hours with blood cultures remaining sterile .


he was fed with a bottle occasionally by his dad and had a vigorous suck and was noted to have some discoordination of his suck while breathing at the initial onset of feeding time .


this was minimized with limitation of volume at each feed with frequent feeding .

frequent feeding
limitation of volume at each feed


infant was circumcised in the newborn nursery which was healing well .


rupture of membranes at time of delivery .


there were no blood products received during hospitalization .


his neck was supple without masses or bruits .


baby was noted to have frequent spitting episodes .


head circumference was 34.5 cm , 75th percentile , and length was 50.7 cm , also the 75th percentile .


there was no electrographic evidence of seizure activity noted .


serologies include blood type o negative , antibody negative , rpr nonreactive .


regular rate and rhythm , no murmur .


mother 's blood type is o negative .


he was noted to have an episode of desaturation related to feeding with desaturations in the 70 percent .


no maternal fever .


in addition a complete blood count was obtained on admission with a white count of 10.1 with 43 polys and 0 bands .

a white count
polys
a complete blood count
bands .


the infant was placed on a cardiopulmonary monitor upon admission to the newborn intensive care unit with pulse oximetry .

a cardiopulmonary monitor
pulse oximetry


the eeg showed transient sharp waves in the left front , left occipital and right parietal regions .


an eeg was performed .


neurology was consulted due to the concern for seizures in the setting of dusky episodes .


full term male infant with cyanosis episodes .


birth weight was 3.29 kilograms in the 75th percentile .


full term well appearing infant with some facial jaundice , overall pink , warm and well perfused , alert and responsive .


immunizations received are hepatitis b vaccine given on 09-26 .


hematocrit was noted to 47.5 with platelets of 257,000 .


a second episode occurred where the baby turned pale .


breast feeding was limited to four to five minutes on each side per recommendation of neurology after their evaluation to try and minimize incidence of gastroesophageal reflux .


there were no sepsis risk factors .


infant 's blood type was o positive and coombs was noted to be negative .


pregnancy was also complicated by maternal history of depression for which mother received zoloft .


ophthalmology was consulted due to the presence of a coloboma into the left cmed .


ophthalmology noted that this left martha coloboma was likely an isolated anomaly in the absence of other pathology .

other pathology
an isolated anomaly
this left martha coloboma


delivery was by repeat cesarean section and apgars of 8 and 9 were given at one and five minutes respectively .


jule remained in room air without any evidence of respiratory distress and was without any further dusky spells or pale episodes in the 48 hours prior to discharge .

respiratory distress
any further dusky spells
pale episodes


on the newborn nursery the mother called the nurse for concern of baby turning dusky while feeding .


baby appeared well and went to the newborn nursery and was breast feeding and undergoing routine newborn care .


red reflexes noted bilaterally .


the baby demonstrated mild physiologic jaundice with a serum bilirubin obtained on day of life three which was 6.7 with a direct of 0.2 .


hearing screening was performed with automated auditory brain stem responses .


he had a left pupil that was in unequal in size with a keyhole appearance consistent with a coloboma .

a keyhole appearance
a coloboma
unequal in size


this episode was also accompanied by gagging motions noted of the infant .


newborn state screen was sent on day of life three .


gbs negative .


pregnancy was uncomplicated until an occurrence of hsv outbreak occurred on 2017-09-13 approximately one week prior to delivery .


on day of delivery mother presented in spontaneous labor .


peggy hammock is a full term baby boy born at 38 1/7 weeks by repeat cesarean section to a 34 year old gravida iii , now para ii mother .


rule out sepsis .


group b strep screening was negative .


2 plus femoral pulses were noted .


weight at time of discharge is 3.13 kilograms .


blood pressure 84/43 with a mean of 59 .


antibiotics were discontinued on day of life three and infant has remained clinically well off antibiotics .


the neonatal intensive care unit was notified and the baby was transferred to the newborn intensive care unit for further evaluation .


the baby did not turn blue at that time .


left coloboma .


renee remained cardiovascularly stable with ap s noted to be 120 to 130 s.


tone was appropriate for gestational age with equal strength , symmetric reflexes .


rule out seizures .


he received a normal saline bolus of 2 liters of good blood pressure response .


liver function tests : alt 38 , ast 34 , alk phos is 107 , albumin is 3.2 , peak bili is 0.3 , amylase 31 , and lipase is 32 .

liver function tests
ast
alk phos is
peak bili is
albumin
amylase
alt
lipase


positive bowel sounds , nontender and nondistended .


serum osmolality was 38397 , calculated osmolality gap was 21 .

serum osmolality
calculated osmolality gap


the patient denies any chest pain , shortness of breath , dysuria , diarrhea , bright red blood per rectum .

dysuria
diarrhea
shortness of breath
bright red blood per rectum
any chest pain


1. hypertension .


in the past , he has been very depressed and has seen a counselor at greenfield community college community health .


mr. pohl is a 53 - year-old male with history of alcohol use and hypertension .


chem-7 : sodium 145 , potassium 3.4 , chloride 116 , bicarb 21 , bun 12 , creatinine 0.6 , glucose 96 , calcium 7.2 , phos 3.6 , magnesium 1.7 .

chloride bun calcium phos chem-7 creatinine sodium magnesium potassium bicarb glucose


we decided to discontinue telemetry and held all hypertension medications including lisinopril , mavik , hydrochlorothiazide .

hydrochlorothiazide
all hypertension medications
mavik
lisinopril


mr. pohl is a 53 - year-old male with a history of etoh , hypertension who presented int he emergency room with increased agitation , like secondary to etoh intoxication and developed subsequent hypotension , systolic blood pressures in the 80 's, status post ativan and haldol , but was responsive

hypertension
subsequent hypotension
etoh intoxication
increased agitation


cbc : white blood cell count is 8.8 , hematocrit 35.5 platelets 266 , pt 13 , pt-t 23.3 , inr was 1.1 .

inr
pt-t
hematocrit
cbc
platelets
pt
white blood cell count


systolic blood pressure in the 120 's to 130 's.


2. history of colonic polyps times 3 , benign in 2007 , repeat colonoscopy due to in 2010 .


no murmurs , rubs or gallops .


ciwa scale over night was 1 for tremor and the patient did not require any valium for alcohol withdrawal .


there was bran atrophy and right temporal encephalomalacia .

bran atrophy
right temporal encephalomalacia


the patient was asymptomatic without chest pain , shortness of breath and no mental status changes .

asymptomatic
chest pain
mental status changes
shortness of breath


rare crackles on the right base , otherwise clear to auscultation bilaterally .


he by emergency room report , was found in his apartment lobby agitated .


pulse in the 60 's to 70 's.


the patient was a thin well-appearing man who was visibly restless in bed .


agitated in emergency room requiring 4 leather restraints , received 5 mg of haldol , 2 mg of ativan .


3. history of colonic polyp times 3 , benign in 2007 , repeat colonoscopy due in 2010 .


calcium carbonate 500 mg p.o. t.i.d. , mag oxide 400 mg p.o. times one dose , potassium chloride repleted 40 meq times one dose .

potassium chloride
mag oxide
calcium carbonate


1. etoh intoxication .


the patient responded well to fluid resuscitation .


1. blood pressure :


the patient became notably less anxious throughout hospital stay .


serum tox was positive for etoh at 383 , otherwise negative .


the patient on ranitidine 150 mg p.o. b.i.d. for gastrointestinal prophylaxis .


head , ears , eyes , nose and throat : atraumatic and normocephalic .


we will given valium 5 mg p.o. q. 3 hours for withdrawal .


we will consider psychiatry consult in the future to assess for underlying anxiety disorder or depression .


the patient 's blood pressure remained stable on hospital day #2 through hospital day #3 status post iv hydration with systolic blood pressures in the 120 's to 130 's.

the patient 's blood pressure
systolic blood pressures


2. hypertension .


return to home medications :


mag was 1.7 , repleted with magnesium oxide with 400 mg p.o. times one dose .


2. thiamine 100 mg q.d.


plan for patient regarding cardiac , unlike hypotension of cardiac origin .


chest x-ray from 02-07 had linear atelectasis in right lower lobe with no evidence of a band-like opacity in the left lower lobe which was evident on the chest x-ray on 02-06 .


2. mavik question of dosage .


vital signs were stable .


no hepatosplenomegaly .


his brother is mentally handicapped and might be sent away from his instate institution .


he had atelectasis in the right lower lobe by chest x-ray .


no stigmata of iv drug use .


to fluid resuscitation at 4 liters and was admitted to the cmed ccu for hemodynamic monitoring .


3. history of right inguinal hernia in 2002 .


he had dorsalis pedis in radial pulses , hands and feet notably tremulous without asterixis .

asterixis
hands and feet notably tremulous


he was alert and oriented times 3 and with slightly pressured speech .


k was 3.4 , repleted , potassium chloride 40 meq times 1 dose p.o.


he does complain of cold symptoms times one week .


calcium with 7.2 corrected to less than 8.0, completed calcium carbonate at 500 mg blood pressure.o. t.i.d. while in the hospital .


we will monitor for signs of alcohol withdrawal according to the ciwa scale .


the patient may be discharge harry 02-08 pending observations for delirium tremens after discussion with primary care physician , dr. blue who knows the patient well .


he uses condoms consistently .


the patient seemed notably anxious and depressed .


he became hypotensive in the emergency room with a systolic blood pressure in the 80 's and had decreased respiratory rate .


elevated ck on 02-07 is likely secondary to mild rhabdomyolysis .


ct of the head on 02-06 was negative for hemorrhage .


1. lisinopril 5 mg p.o.q.d.


sclerae were anicteric .


1. lisinopril 5 mg p.o. q.d.


major stressors in his life include unstable job , brother is mentally handicapped , war .


2. mavik unknown dosage .


it is possible that the patient is self medicating for underlying psychiatric disorder .


the patient states in the past that he has participated in several alcohol treatment programs , most recently star which is similar alcoholics anonymous .


cranial nerves ii-xii are grossly intact , 5/5 strength in all extremities , sensation is intact in all extremities .

strength in all extremities
sensation
cranial nerves ii-xii


the patient was urinating without difficulty .


positive tobacco , 10 pack year history , quit for 8 years in his 40 's and now no cigarettes for one week using no pharmacal therapy .


ua was negative .


the patient has only male sexual partners and in the last six months has two regular partners who reportedly are human immunodeficiency virus negative and no iv drug use .


2. for pulmonary , the patient had a good o2 saturations on room air .


we continued iv fluids at 100 cc per hour for one liter secondary to a concern for rhabdomyolysis plus kidney protective effects .


vitals on admission : please refer to addendum .


blood alcohol level was 383 .


he was found in his apartment lobby " shouting " and very agitated .


urine tox was negative .


we continued to hold the patient 's home blood pressure medications .


4. multivitamin


the patient was then admitted to the medical intensive care unit for observation of his blood pressure and then transferred to our service on medicine when the blood pressures remained stable overnight .


3. folic acid 1 mg q. d.


he denies auditory , visual or tactile hallucinations .


oropharynx was benign without exudate .


3. hydrochlorothiazide question of dosage .


1. ranitidine 150 mg b.i.d.


4. history of right inguinal hernia in 2002 .


he states that mood is depressed .


4. urology : foley was discontinued in the cmed ccu at 12 p.m.


3. hydrochlorothiazide unknown dosage .


on hospital day #2 through hospital day #3 , the patient had mild tremor on hands , but improved over hospital course .


allergies : no known drug allergies .


this is an 82 - year-old male with a history of prior tobacco use , hypertension , chronic renal insufficiency , copd , gastritis , and tia who initially presented to braintree with a non-st elevation mi and guaiac positive stools , transferred to st. margaret's center for women & infants for cardiac catheterization with ptca to mid lad lesion complicated by hypotension and bradycardia requiring atropine , iv fluids and transient dopamine possibly secondary to vagal reaction , subsequently transferred to ccu for close monitoring , hemodynamically stable at the time of admission to the ccu .

a non-st elevation mi
gastritis
vagal reaction
hypotension
bradycardia
tia
guaiac positive stools
mid lad lesion
copd
chronic renal insufficiency
hypertension

close monitoring
cardiac catheterization

transient dopamine
iv fluids
atropine
ptca


he had 2+ dorsalis pedis and posterior tibial pulses bilaterally .


the symptoms were associated with diaphoresis and shortness of breath but no nausea or vomiting .

diaphoresis
nausea
shortness of breath
the symptoms
vomiting


heart rate 91 , regular , blood pressure 169/81 from a right groin a line , respirations 12 , oxygen saturation of 97 percent on 2 liters nasal cannula .

heart rate
blood pressure
respirations
oxygen saturation

a right groin a line
2 liters nasal cannula


he had no evident edema .


his ace inhibitor post mi was initially held due to his creatinine .


he was initially continued on aspirin , plavix , beta blocker , statin , and ace inhibitor .

statin
aspirin
ace inhibitor
beta blocker
plavix


he was continued on his mdi and was at his baseline 02 requirement throughout admission .


at the time of transfer , he was initially admitted to the cmi service after undergoing cardiac catheterization which revealed a long lad lesion that was angioplastied without stent placement , and a total occlusion of the rca with collaterals .

a long lad lesion
a total occlusion of the rca


he had a history of copd for which he is on baseline 2 liters of 02 by nasal cannula at home and albuterol and atrovent mdi s p.r.n. at home .


there was a right groin a line and a left groin venous sheath with a swan .

a right groin a line
a swan
a left groin venous sheath


he had a transthoracic echocardiogram the day after admission showing an ejection fraction of greater than 60 percent .

an ejection fraction
a transthoracic echocardiogram


it was felt most appropriate for him to have an outpatient gi workup , and his pcp was contacted and will arrange for outpatient colonoscopy .

outpatient colonoscopy
an outpatient gi workup


he had a bedside transthoracic echocardiogram done in the cardiac catheterization laboratory without evidence of an effusion .


gastritis .


1. aspirin 325 mg q.d.


serum chemistries revealed a sodium of 135, potassium 4.0 , chloride 102 , bicarbonate 26 , bun 29 , creatinine 1.6 , and glucose of 111 .

bun
a sodium
creatinine
bicarbonate
glucose
serum chemistries
potassium
chloride


vital signs :


he subsequently became hypotensive and bradycardiac in the catheterization laboratory which responded to iv fluids , dopamine , atropine , and he was then transferred to the ccu for further monitoring .


by the time he was admitted , he was off pressors and hemodynamically stable and pain-free .


at the time of discharge , the patient 's vital signs were stable and he was without complaints .


as summarized above , the patient had a non-st elevation mi with evidence of an 80 percent mid lad lesion for which he underwent angioplasty without stent placement .

an 80 percent mid lad lesion
a non-st elevation mi


no focal wall motion abnormalities .


the ekg was prior to catheterization and the one post ptca was no different .


however , this responded to iv fluids and his ace inhibitor was restarted at the time of discharge .


his stools were noted to be guaiac positive at the outside hospital and there was still concern for possible gi bleed given continued guaiac positive stools during this admission and a slight drop in his hematocrit from 39 to 33 .

gi bleed
guaiac positive stools
a slight drop in his hematocrit
guaiac positive


he also had a widened qrs of 153 milliseconds , an old right bundle branch block , and no acute st or t wave changes .

an old right bundle branch block
acute st or t wave changes
a widened qrs


the right heart catheterization revealed pulmonary capillary wedge pressure of 4 , cardiac output of 8 , and cardiac index of 3.8 , he had an ra pressure of 10 , rv pressure of 43/4 , pa pressure of 37/10 .

cardiac index
the right heart catheterization
an ra pressure
cardiac output
rv pressure
pa pressure
pulmonary capillary wedge pressure


there were no stents deployed at all throughout the catheterization .


his plavix was held at the time of discharge due to a question of gi bleed and in the setting of not having a stent placed at the time of catheterization .


5. heparin drip on transfer .


1. lipitor 10 mg q.d.


the patient was subsequently transferred to youville hospital for cardiac catheterization .


4. mdi p.r.n.


at the time of discharge , his plavix was held due to guaiac positive stools and hematocrit drop throughout admission .


the patient has no known drug allergies .


he was started on nitrates there as well as heparin and integrelin and remained pain-free .


the initial ekg showed normal sinus rhythm at a rate of 71 with a normal axis and evidence of first-degree av block with prolonged pr interval of 238 milliseconds .

prolonged pr interval
first-degree av block

sinus rhythm
a rate
axis
the initial ekg


chronic renal insufficiency .


a swan was also placed .


he had normoactive bowel sounds .


3. flovent 110 micrograms aerosol two puffs b.i.d.


after approximately one hour , he presented to the bristol county tuberculosis hospital dana-farber cancer institute campus where he ruled in for a non-st elevation mi with a ck of 438 with a peak ck mb of 19.8 and troponin that peaked at 10.2 .


he had no recurrent chest pain or shortness of breath throughout admission .

shortness of breath
recurrent chest pain


cardiac catheterization revealed a totally occluded rca with collaterals , an 80 percent lad lesion extending distally which was angioplastied but no stent was placed .

an 80 percent lad lesion
a totally occluded rca


tia in 1998 .


he also had bilateral arm numbness .


the patient is an 82 - year-old male with a history of hypertension , remote tobacco abuse , chronic renal insufficiency , and a history of a tia who was in his usual state of health until five nights prior to admission when he awoke at midnight with severe epigastric pain radiating to both arms .

severe epigastric pain
chronic renal insufficiency
a tia
hypertension


his lungs were clear to auscultation bilaterally anteriorly and laterally .


coronary artery disease , status post non-st elevation myocardial infarction with 80 percent mid lad lesion , now status post angioplasty .

80 percent mid lad lesion
non-st elevation myocardial infarction
coronary artery disease


he had a bedside echocardiogram done in the catheterization laboratory which showed normal lv wall thickness and normal lv cavity size .


5. combivent mdi p.r.n.


on admission , the cbc revealed a white count of 7.4 , hematocrit 39.7 , and platelets of 217,000 .

hematocrit
the cbc
a white count
platelets


in regards to his rhythm , he has an underlying right bundle branch block and first-degree av block which were stable throughout this admission .

first-degree av block
an underlying right bundle branch block


he denied any history of similar symptoms in the past and has had no prior history of angina or myocardial infarction .

myocardial infarction
similar symptoms
angina


2. metoprolol 50 mg b.i.d.


he was continued on his aspirin , however .


he will need close monitoring of his creatinine post discharge in the setting of reinstitution of his ace inhibitor .


crusting around the right eyelid but the pupils were equal , round , and reactive to light .


he had no murmurs , rubs , or gallops .


he uses a cane p.r.n. for walking .


4. aspirin 325 mg q.d.


he was edentulous .


he has a history of chronic renal insufficiency likely secondary to hypertension and was admitted with a creatinine of 1.6 .

hypertension
chronic renal insufficiency


asthma .


there was no evidence of effusion .


it was discussed with him the need to schedule follow-up for colonoscopy with his pcp as well .


3. lipitor 10 mg q.d.


bph .


he is also on flovent mdi at home as well .


2. lisinopril 2.5 mg q.d.


copd with 2 liters dependence of home 02 .


soft , obese , nontender , nondistended .


the neck was supple without lymphadenopathy or thyromegaly .


6. integrelin drip on transfer .


chronic obstructive pulmonary disease .


chronic renal insufficiency .


anemia .


6. toprol xl 100 mg q.d.


guaiac positive stools .


he was a well appearing male in no acute distress .


hypertension .


upon discharge the patient was changed to a bid protonix regimen .


her hct dropped from hct 38.9 before fluids to 35.5 s/p 1.5l ns and was thought to be dilutional .


she will need outpatient follow up for her guiac pos stools with endoscopy vs egd +/- h.pylori serologies .


7. tiotropium bromide 18 mcg capsule , w/ inhalation device sig : one ( 1 ) cap inhalation daily ( daily ).


4. guiac pos stool : given the patient 's sx of gerd , current po steroid regimen , and asa for her stents , the ddx for her guiac positive stools would include gastritis / gastric ulcer in addition to lower gi pathology .

guiac pos stool
her guiac positive stools
gastritis
gastric ulcer
lower gi pathology
gerd


13. oxygen continue 02 at 1l/min continuous to keep sats in 90 's.


she also has no gross blood per rectum and her hct is stable .


infection / sepsis was not likely given she was afebrile and had no localizing sx with an improving lung exam and 02 requirement .

afebrile
02 requirement
sepsis
infection
localizing sx


9. albuterol sulfate 0.083 % solution sig : one ( 1 ) puff inhalation q6h ( every 6 hours ) as needed for shortness of breath or wheezing .


therefore , the cause of her mild diarrhea ( few loose bm / liquid stool / night ) may be either viral or secondary to resolving abdominal hematoma with resultant irritation of gi system .

irritation of gi system
viral
resolving abdominal hematoma
liquid stool
her mild diarrhea
few loose bm


stool for c.diff toxin was sent x 1 and was negative .


all of this occurred in the setting of aggressive bp management with metoprolol 25 bid , hctz / triampterene ( as a replacment for lasix due to recurrent hypokalemia ), benicar 20 mg qd , and imdur 30 mg qd .

metoprolol
lasix
imdur
benicar
hctz
aggressive bp management
triampterene


her bowel regimen is prn .


2. thrush : this is likely secondary to her steroid inhalers and po prednisone for copd exacerbation .


she was asymptomatic .


the patient was encouraged to take po liquids to prevent volume depletion .


you must take your aspirin and plavix every day to prevent failure of these stents which could be life threatening .


3. diarrhea : the patient has been having loose stools at night and was guiac pos x 2 .


she will need follow up with her pcp within b week after discharge from the extended care facility for further bp titration and monitoring of her electrolytes .


the hypotension was likely due to volume depletion caused by her diarrhea / loose stools in addition to decreased po intake secondary to her gerd and thrush .

loose stools
the hypotension
volume depletion
her diarrhea
decreased po intake
her gerd
thrush


she was also placed on on low dose spironolactone as a k sparing diuretic and for bp control in addition to toprol xl 25 mg qd for her coronary disease .

bp control
low dose spironolactone
a k sparing diuretic
toprol xl


4. oxycodone 5 mg tablet sig : one ( 1 ) tablet po q4h ( every 4 hours ) as needed for pain .


the patient was kept an additional two days to follow her hcts and titrate her bp meds .


as volume depletion was thought to be the cause of her low bp , only the bblocker was restarted .


just prior to discharge on 11-14 , pt 's bp was found to be 70/40 p70 s just after receiving her am bp meds .


sulfa ( sulfonamides ) / penicillins / macrodantin / ivp dye , iodine containing

iodine containing
penicillins
macrodantin
ivp dye
sulfa ( sulfonamides


however , she has no vomiting and only mild nausea with medications .


gastroenteritis is possible but she has no vomiting and only occ nausea with meds .


2. pantoprazole 40 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po twice a day .


she tolerated these meds with sbp s in the high 90 s to 100 s and was therefore discharged on this regimen .


16. nystatin 100,000 unit / ml suspension sig : ten ( 10 ) ml po qid ( 4 times a day ) for 7 days .


17. aspirin 325 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po daily ( daily ).


given the patient 's recent rp bleed , there was concern for a recurrent bleed .

the patient 's recent rp bleed
a recurrent bleed


we have advised a brat diet .


if you experience cp , sob , dizzyness , or any other symptoms that concern you please call your pcp or return to the er .


2) retroperitoneal bleed


1. hypotension : the patient 'd pm bp meds were held 11-14 and she was administered 1.5l ns over the course of the day with subsequent sbp s in the high 90 s, low 100 s,.


15. metoprolol succinate 25 mg tablet sustained release 24hr sig : one ( 1 ) tablet sustained release 24hr po daily ( daily ).


6. fluticasone 110 mcg / actuation aerosol sig : two ( 2 ) puff inhalation bid ( 2 times a day ).


10. aluminum - magnesium hydroxide 225-200 mg / 5 ml suspension sig : 15-30 ml s po prn ( as needed ).


14. spironolactone 25 mg tablet sig : 0.5 tablet po daily ( daily ).


1) rapid atrial fibrillation with demand ischemia

demand ischemia
rapid atrial fibrillation


repeat hcts were stable .


11. senna 8.6 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ) as needed .


8. clopidogrel 75 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


12. prednisone 10 mg tablet sig : 1-2 tablets po daily ( daily ) for 4 days : please take two pills for one day starting 11-17 , then take one pill for three days .


there is no evidence of obstruction on axr .


1. atorvastatin 10 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


she was started on nystatin swish and swallow qid .


please take all medications as prescribed .


3. acetaminophen 500 mg tablet sig : two ( 2 ) tablet po q6h ( every 6 hours ).


5. fluticasone 50 mcg / actuation aerosol , spray sig : two ( 2 ) spray nasal daily ( daily ).


her groin exam was unchanged .


note : you have had a cardiac stent placed during this admission .


2) you are scheduled to have your staples removed on 2013-11-20 3:00 with provider : leah , paula g. wilson surgery ( nhb )


ekg s were followed for normalization .


at baseline the patient denies any previous chest pain , pressure , dyspnea on exertion , orthopnea , pnd or palpitations .

palpitations
dyspnea
orthopnea
pressure
previous chest pain
pnd