meds at transfer : levoxyl , celexa , folate , lopressor , colace , riss , b12 , protonix , lasix , zocor , verapamil , lovenox , lisinopril

folate lopressor meds celexa levoxyl lasix colace lisinopril lovenox verapamil riss protonix zocor b12


brother w/ cad since age 40 and died in 70 's after cardiac surgery .


she underwent an immediate head ct and neuro consult and was transferred back to the csru .


2015-11-12 06:00 am blood wbc - 7.7 rbc - 2.73 * hgb - 8.3 * hct - 25.1 * mcv - 92 mch - 30.4 mchc - 33.1 rdw - 15.5 plt ct - 528 *

rbc
wbc
hct -
mcv
hgb
rdw
mch
mchc
plt ct


resting regional wall motion abnormalities include mild apical hypokinesis .


meds at home : coumadin , levoxyl , folate , colace , byetta , verapamil , lisinopril , pravachol , nexium , lasix , celexa

nexium celexa lasix verapamil pravachol lisinopril colace byetta coumadin meds levoxyl folate


son died at 14 d/t asd .


2015-11-11 05:45 am blood pt - 14.5 * ptt - 51.4 * inr(pt) - 1.3 *


2015-11-11 05:45 am blood creat - 1.6 * k - 4.7


there is evidence of prior cardiac surgery .


cxr 11-06 : allowing for technical changes , no major adverse interval change has occurred .


cnis 10-29 :


gen : nad


2015-10-28 03:30 pm blood glucose - 98 urean - 26 * creat - 1.6 * na - 140 k - 4.6 cl - 104 hco3 - 27 angap - 14


she was then started on heparin with transition to coumadin ( goal inr of 2-3 secondary to h/o bilateral dvt 's).


ct 11-04 : no acute intracranial hemorrhage .


coronary artery disease , hypertension , hyperlipidemia , diabetes mellitus , hypothyroid , h/o bilateral dvt 's ( on chronic coumadin therapy ), pleural disorder ? sarcoidosis , gastritis , b12 deficiency , chronic renal insufficiency , s/p appendectomy , s/p lap cholectomy , s/p total abdominal hysterectomy

diabetes mellitus
chronic renal insufficiency
hypothyroid
hypertension
hyperlipidemia
coronary artery disease
bilateral dvt 's
gastritis
b12 deficiency
sarcoidosis
pleural disorder

appendectomy
total abdominal hysterectomy
lap cholectomy
chronic coumadin therapy


2015-11-12 06:00 am blood glucose - 85 urean - 19 creat - 1.6 * na - 140 k - 4.4 cl - 105 hco3 - 24 angap - 15


epicardial pacing wires were removed on post-op day four .


after remaining stable in the csru for several days without change in neuro status she was transferred back to the sdu on post-op day four .


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


ms. bridge is a 74 y/o female admitted to outside hospital on 2015-10-21 with chest discomfort , vomiting and shortness of breath .

shortness of breath
vomiting
chest discomfort


10. metoprolol tartrate 25 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ).


she eventually underwent a cardiac cath to assess coronary disease which revealed three vessel coronary artery disease .

three vessel coronary artery disease
coronary disease


9. folic acid 1 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


2015-11-12 06:00 am blood pt - 15.5 * ptt - 62.4 * inr(pt) - 1.4 *


initial ekg showed st depressions , but cardiac enzymes were not elevated .


later on op day sedation was weaned , she awoke neurologically intact and was extubated .


12. coumadin 5 mg tablet sig : one ( 1 ) tablet po once a day : check inr 11-15 with results called to dr. lynn .


2015-11-02 coronary artery bypass graft x 2 ( lima to lad , svg to om )

coronary artery bypass graft
lima to lad
svg to om


there are complex (> 4 mm ) atheroma in the descending thoracic aorta .


5. citalopram 20 mg tablet sig : 0.5 tablet po daily ( daily ).


2015-10-30 left carotid stenting


4. simvastatin 40 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


tape / benadryl


13. tramadol 50 mg tablet sig : one ( 1 ) tablet po q4-6h ( every 4 to 6 hours ) as needed .


monitor wounds for signs of infection . please call with any concerns or questions .


8. ascorbic acid 500 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ).


7. ferrous gluconate 300 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


no lifting more than 10 lbs for at least 10 weeks from the date of surgery .


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


no creams , lotions or ointments to incisions .


mother died of mi at age 55 .


pmh : hypertension , hyperlipidemia , diabetes mellitus , hypothyroid , h/o bilateral dvt 's, pleural disorder ? sarcoidosis , gastritis , b12 deficiency , chronic renal insufficiency , s/p appendectomy , s/p lap cholectomy , s/p total abdominal hysterectomy

b12 deficiency
gastritis
diabetes mellitus
sarcoidosis
bilateral dvt 's,
hypertension
pleural disorder
chronic renal insufficiency
hyperlipidemia
hypothyroid

total abdominal hysterectomy
lap cholectomy
appendectomy


she underwent usual pre-operative testing along with carotid ultrasound .

usual pre-operative testing
carotid ultrasound


on 11-02 she was brought to the operating room where she underwent a coronary artery bypass graft x 2 .


she tolerated the procedure well and was transferred to the csru for invasive monitoring in stable condition .


post-operative transient ischemic attack


cnis revealed carotid stenosis and she ultimately underwent left carotid stenting by vascular surgery on 10-30 .


coronary artery disease s/p coronary artery bypass graft x 2


heart : rrr - c/r/m/g


ext : cool , 1 + pedal pulses , - varicosities , - edema


some rashes on acw around ekg leads


1. 60-69% stenosis of the right internal carotid artery .


2. 80-99% stenosis of the left internal carotid artery .


carotid stenosis s/p left carotid stenting


complications .


the aortic valve leaflets ( 3 ) appear structurally normal with good leaflet excursion and no aortic regurgitation .


the mitral valve appears structurally normal with trivial mitral regurgitation .


ct angiogram demonstrates no stenosis or aneurysm in the intracranial circulation .


2015-11-13 06:15 am blood pt - 18.0 * ptt - 62.3 * inr(pt) - 1.7 *


mild tricuspid regurgitation .


trivial mr .


she was then transferred to the hospital for orthopedics for surgical intervention .


abd : soft , nt/nt + bs


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


neck : supple , - jvd , - bruits


lungs : ctab , coarse


3. levothyroxine 125 mcg tablet sig : one ( 1 ) tablet po daily ( daily ).


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


ct was negative and she returned to baseline neuro status without deficits by arrival to csru .


ms. bridge was admitted from osh for coronary artery bypass surgery .


left-sided subclavian line is unchanged in position .


early on post-op day two ms. bridge had an episode of aphasia .


2015-11-13 06:15 am blood plt ct - 583 *


neurology concluded episode was most concerning for tia .


bibasilar subsegmental atelectasis together with bilateral pleural effusions appear relatively unchanged .

bibasilar subsegmental atelectasis
bilateral pleural effusions


mri would be more sensitive for the detection of acute infarction .


on post-op day one chest tubes were removed and beta blockers and diuretics were initiated .


2015-11-13 06:15 am blood glucose - 96 urean - 20 creat - 1.6 * na - 141 k - 4.3 cl - 106 hco3 - 24 angap - 15


chest discomfort


findings consistent with small vessel ischemic changes .


normal contrast enhancement seen in the left common/internal carotid artery stent .


slight irregularity of the origin of the right vertebral artery may be atherosclerotic in nature .


in the absence of history of malignancy , this is statistically benign .


4 mm left upper lobe lung nodule .


mild stenosis of the proximal right internal carotid artery .


14. lasix 40 mg tablet sig : one ( 1 ) tablet po once a day : 40 mg daily x 1 week then 40 mg every other day as prior to surgery .


3. community-acquired pneumonia .


2. bronchitis .


briefly , this is a 57-year-old gentleman with a history of copd , status post intubation six years ago but not on home 02 with recent fev1 27% of predicted value , and fev1/fvc ratio 56% of hypercholesterolemia , who was admitted for copd exacerbation and worsening of upper respiratory tract infection symptoms for a week prior to admission .


he was also started on antibiotics for possible bronchitis or community-acquired pneumonia .


he was started on p.o. steroids and to cmed for management of copd exacerbation but he appeared in more respiratory distress overnight and was started on iv solu-medrol and more frequent nebulizers for copd .

copd
copd exacerbation
more respiratory distress

management
p.o. steroids
more frequent nebulizers
iv solu-medrol


he was afebrile with stable vital signs on presentation to


1. chronic obstructive pulmonary disease exacerbation .


therefore , home 02 was recommended on discharge .


6. oxygen 2 liters nasal cannula with ambulating as needed .


he was continued on p.o. prednisone and frequent nebulizers for copd .


given his tenuous respiratory status , he was transferred to the ficu with closer observation .


5. salmeterol one to two puffs b.i.d.


he was evaluated by the physical therapist in the hospital and was found to desaturate to 84% with ambulating on room air .


he did not require intubation and improved with q. two hour nebulizers and chest pt .


1. flovent two puffs b.i.d.


he was again transferred to the cmed service for further management of his copd exacerbation .


3. albuterol inhaler one to two puffs q. four to six hours p.r.n.


4. aspirin 81 mg p.o. q.d.


7. prednisone taper with 40 mg p.o. q.d. for two days , 30 mg p.o. q.d. for two days , 20 mg p.o. q.d. for two days , 10 mg p.o. q.d. for two days .


2. levofloxacin 500 mg p.o. q.d. for another 11 days for a total of a 14 day course .


4. rule out myocardial infarction .


the patient was admitted with concern for hepatorenal syndrome .


the patient received 5 liters of crystalloid , 9 units of fresh frozen plasma , 9 units of red cells , 6 units of platelets , as well as 1 liter of cell saver .

fresh frozen plasma
crystalloid
platelets
red cells
cell saver


the patient was on a lasix drip to aid in diuresis , and was ultimately converted to oral lasix on postop day 1 .


his estimated blood loss was 2 liters .


in order to aid in optimization of the patient 's fluid status , the patient was on continuous baker baker dialysis during the procedure .

the procedure
continuous baker baker dialysis


1. hepatitis c cirrhosis for which the patient was on the liver transplant list .


the patient is a 47 year old male , with end stage liver disease secondary to hepatitis c cirrhosis diagnosed about 5 years prior to admission .

end stage liver disease
hepatitis c cirrhosis


the patient 's inr on admission was 2.4 , with his pt level being 18.9 .


1. miconazole nitrate powder tid prn for groin rash .


liver transplant on 2013-05-25 .


he had been admitted to the st. margaret 's center for women & infants multiple times early in 2013 for management of encephalopathy and ascites .


the patient was advanced per protocol to an immunosuppressive regimen of prednisone , neoral , and cellcept .

an immunosuppressive regimen
prednisone
neoral
cellcept


the patient required 2 units of fresh frozen plasma on the night following surgery , and 1 unit of platelets on postop day 1 , but otherwise required no blood products following the liver transplant .

the liver transplant
platelets
blood products
fresh frozen plasma
surgery


3.2 on 2013-05-08 , and was further elevated to 3.6 on 2013-05-09 .


the patient 's serum creatinine on the day of discharge , on 2013-05-06 , was 1.9 , but was noted to increase to


4. vancomycin 1 gm iv bid .


9. valcyte 450 mg po qod .


he had no evidence of spontaneous bacterial peritonitis .


8. neoral 500 mg po bid .


the procedure proceeded without complications , and the patient was transferred to the intensive care unit while still intubated following the procedure .


the patient 's nutrition was suboptimal , and the patient was started on tube feeding .


11. colace 100 mg po bid .


10. lasix 40 mg bid x 21 days .


as previously mentioned , the patient 's creatinine at the time of admission was up to 3.6 from 1.9 at the time of his discharge 3 days prior .


6. prednisone 20 mg po qd .


the patient had been discharged from the st. margaret 's center for women & infants on 2013-05-06 , but was readmitted on 2013-05-09 when noted to have worsening renal function .


the patient was taken to the operating room and underwent an orthotopic liver transplant .


7. dilaudid prn .


the patient 's pain control was with morphine .


on 2013-05-25 , a liver became available for transplant to the patient .


4. fluconazole 200 mg po qd .


the patient periodically required transfusions of fresh frozen plasma , as well as platelets and red cells .

red cells
platelets
fresh frozen plasma
transfusions


3. metoprolol 25 mg po bid .


the patient 's surgical incision was also healing well by the time of discharge with no evidence of infection .

the patient 's surgical incision
infection


the patient was thrombocytopenic with a platelet count of 49 on the 23 .


6. back surgery .


2. protonix 40 mg po qd .


the patient had undergone treatment with interferon and ribavirin .


by postop day 1 , the patient was awake , in no distress , and appeared lucid prior to extubation .


5. cellcept 1 gm po bid .


the patient was continued on vancomycin therapy for his previously diagnosed methicillin resistant , coagulase negative staph bacteremia .


the patient started ambulating with the assistance of physical therapy following transfer to the surgical floor .


the patient 's appetite improved significantly , and at the time of discharge the patient was on a regular diet with no tube feed supplements deemed necessary .


over the following 5 days , the patient 's creatinine improved marginally to 2.7 .


the patient 's liver function tests all improved appropriately by the time of discharge .


5. knee surgeries .


1. bactrim single strength 1 tablet po qd .


the patient was extubated on postop day 1 without any problems .


the patient underwent diagnostic and therapeutic paracentesis on 2013-05-16 , 2013-05-21 , and 2013-05-24 .


optimization of his fluid balance was managed by the medical service in consultation with hepatology and renal .


3. lactulose 30 ml tid ( titrated to 4 to 5 bowel movements qd ) .


2. protonix 40 mg po bid .


4. hemorrhoids .


2. hypertension .


3. nephrolithiasis .


cadaveric pancreas transplantation .


in addition , she will take valganciclovir for three months posttransplant .


she takes 14 units of nph insulin twice a day supplementing with a sliding scale .


she has undergone full teaching in regards to immunosuppressant medications .


the patient is a 37 year old lady with type 1 diabetes mellitus , who is four months postcadaveric kidney transplantation and now has good graft function .


she is to continue monitoring her blood sugar twice a day .


on examination , she is in no apparent distress and is alert and oriented .


she is afebrile with stable vital signs .


3. end stage renal disease , status post kidney transplantation .


2. type 1 diabetes mellitus .


her abdomen is soft and nontender with a well healed left lower quadrant incision from her kidney transplantation .


1. status post cadaveric pancreas transplant .


she underwent cadaveric pancreas transplantation without complication .


her chest and cardiovascular examinations are unremarkable .


she presents for cadaveric pancreas transplantation .


she received induction therapy with thymoglobulin intraoperative and postoperatively for five days .


her diabetes mellitus has been complicated by retinopathy and nephropathy as well as peripheral neuropathy .

her diabetes mellitus
retinopathy
nephropathy
peripheral neuropathy


she was kept on a similar immunosuppressive regimen as with her kidney transplant .

a similar immunosuppressive regimen
her kidney transplant


rr nl s1 s2 no m


plastic did not feel that patient had any compartment syndrome and recommended aggresive upper extremity elevation for swelling reduction .

swelling reduction
aggresive upper extremity elevation


atnc , pupils dialted at 5 mm but minimally reactive , anicteric


patient was started on heparin drip and bilateral lower extremeties were done which were negative for dvt .


wwp , multiple linear scars and burns on hands and arms

wwp
burns on hands and arms
multiple linear scars


soft , nd , hypoactive bowel sounds


2014-04-23 08:13 am urine bnzodzpn - pos barbitrt - neg opiates - neg cocaine - neg amphetmn - neg mthdone - neg

opiates cocaine barbitrt urine bnzodzpn mthdone amphetmn


overnight in the icu patient was noticed to have painful bullae on hands and arm along with swelling .

painful bullae on hands and arm
swelling


calcium - 9.7 phosphate - 3.7 magnesium - 2.1


later patient told cmed ccu that she was feeling down and impulsively ingested 5 days worth of medications , she states that her intent at that time was to end her life .


patient had cta which showed bilateral pulmonary embolisms .


dermatology and plastic surgery were consulted who felt that symptoms were due to trauma ; it was not felt that patient had compartment syndrome .


patient has a history of suicidal ideations and self mutilation .


4. gerd


she was promptly intubated for airway protection and in order to administer charcoal .


nsr r 60 normal axis , intervals , incomplete rbbb , flat t avl , v2 , twi v1


patient was gradually put back on her outpatient xanax dose of 1 mg qid and clozaril was restarted .


ms. franklin is a 34 - year-old woman with bipolar disorder and group home resident who by way of ems for apparent alprazolam overdose .

apparent alprazolam overdose
bipolar disorder


group home states that patient " may have taken too many xanax .


in the st. margaret 's center for women & infants , the patient was lethargic and unable to give a history .


intubated and sedated


2. asthma .


ct chest - shows bilateral segmental , subsegmental pes


3. posttraumatic stress disorder .


b/l le lenis - negative


wbc - 9.4 # rbc - 4.75 hgb - 14.7 hct - 42.2 mcv - 89 mch - 30.9 mchc - 34.8 rdw - 13.6


2. lamotrigine 100 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ) .


patient was found at group home in am laying on floor by bed unresponsive , last seen awake 8 hours prior at dinner .


vs 95.4 hr 62 bp 99/70 rr 20 o2sat 100%


ekg :


1. bipolar disorder .


4. folic acid 1 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


patient was intubated in john for airway protection and administation of charcoal .


5. multivitamin capsule sig : one ( 1 ) cap po daily ( daily ) .


multivitamin


probable ateletasis of lingula , consistent with pneumonitis


alt ( sgpt )- 21 ast ( sgot )- 40 alk phos - 70 amylase - 59 tot bili - 0.4

alk phos
ast ( sgot
amylase
tot bili
alt ( sgpt )-


cxr :


two sisters with h/o depression and suicidality .


propanolol xl 80 mg qd


abg revealed widened a-a gradient so a d-dimer was sent which was elevated .


5. chronic constipation from laxative abuse .


no rashes or petechiae , linear and burn scars as above


sedated , dtrs :


senna


toxicology consulted and felt that patient most likely had benzo overdose .


patient was put on coumadin that was bridged with lovenox unti linr theraputic 01-23 .


while on the floor patient 's urinalysis suggestive of uti and was put on 6 day course of levofloxacin .


d-dimer - 7998 *


8. warfarin sodium 3 mg tablet sig : one ( 1 ) tablet po at bedtime .


clozapine 300 mg po qhs


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

barbitrt bnzodzpn asa tricyclic ethanol acetmnphn


glucose - 116 * urea n - 14 creat - 1.0 sodium - 137 potassium - 4.5 chloride - 105 total co2 - 20 * anion gap - 17

urea n
potassium
chloride
creat
sodium
anion gap
total co2
glucose


folate 1 mg po qd


clomipramine 100 mg po qhs


pantopraozle 40 mg po qd


intubation for airway protection


trazadone 200 mg po qhs


benzo overdose


lithium - less than


lamictal 100 mg po bid


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


penicillins / sulfonamides


alprazolam 1 mg po qid


please continue to take antibiotics as directed for urinary tract infection for 3 more days .


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


11. alprazolam 1 mg tablet sig : one ( 1 ) tablet po qid ( 4 times a day ) .


blood - neg nitrite - neg protein - neg glucose - neg ketone - tr bilirubin - neg urobilngn - neg ph - 6.5 leuk - neg

leuk blood nitrite ph bilirubin urobilngn ketone protein glucose


plt count - 330


neuts - 73.0 * lymphs - 21.8 monos - 3.8 eos - 1.1 basos - 0.3


digoxin -< 0.2 *


please continue to take coumadin as directed by your doctors until told to stop for clots found in your lungs .


7. clozapine 25 mg tablet sig : one ( 1 ) tablet po hs ( at bedtime ) .


stable - swelling in hands reduced and range of motion continue to improve .


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


2014-04-23 03:45 pm urine


ucg - negative


1. acetaminophen 325 mg tablet sig : 1-2 tablets po q4-6h ( every 4 to 6 hours ) as needed .


ck ( cpk )- 4713 *


10. trazodone hcl 100 mg tablet sig : two ( 2 ) tablet po hs ( at bedtime ) as needed .


bipolar disorder


patient seen by pt and ot who recommended hand exercises and splints for patient .


2014-04-23 08:00 am urine


x-ray of the hands and wrist were obtained which were negative .


while on the floor patient 's hands improved with good range of motion of left hand , however jones some poor range of motion of right .


lipase - 66 *


benzodiazapine overdose


14. nicotine 14 mg / 24 hr patch 24 hr sig : one ( 1 ) patch 24 hr transdermal daily ( daily ) .


12. levofloxacin 500 mg tablet sig : one ( 1 ) tablet po q24h ( every 24 hours ) for 3 days .


modifinal 100 mg po qd


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


patient conitnued to have si while on floor and was transferred to psychiatry .


traumatic / pressure bullae


review of systems was significant for progressive abdominal discomfort , decreased oral intake , and weakness in the past nine weeks .

progressive abdominal discomfort
decreased oral intake
weakness


father had coronary artery disease .


mother had adrenal cancer .


no known drug allergies .


colace , senna , dulcolax , tylenol , oxycodone as needed , ambien , and protonix .

protonix colace senna dulcolax tylenol oxycodone ambien


physical examination revealed temperature was 96.9 , heart rate was 121 , blood pressure was 122/86 , respiratory rate was 22 , and oxygen saturation was 96% on room air .

blood pressure
heart rate
temperature
physical examination
oxygen saturation
respiratory rate


the patient was placed on flagyl and levaquin for treatment of pneumonia .


a thoracentesis was done with removal of 1.5 liters of fluid .


a paracentesis was repeated with removal of 2.5 liters of fluid .


lungs revealed decreased breath sounds and dullness to percussion in the left lung base .


no murmurs , rubs , or gallops .


cardiovascular examination revealed tachycardic first heart sound and second heart sound .


head , eyes , ears , nose , and throat examination revealed the oropharynx was clear .


the abdomen was distended and firm .


sclerae were anicteric .


this was a 55 - year-old gentleman with recently diagnosed abdominal carcinomatosis admitted with increased abdominal pain and poor oral intake .


the patient was admitted to the o-cmed service for further management .


he was placed on a patient-controlled analgesia for pain control .

pain control
a patient-controlled analgesia


in general , the patient looked acutely and chronically ill .


extremity examination revealed no clubbing , cyanosis , or edema .


on 05-03 the patient underwent an abdominal ultrasound with paracentesis , and 5 liters of fluid were removed .


he was continued on heparin for treatment of the pulmonary emboli .


the patient is a 55 - year-old male with recently diagnosed abdominal carcinomatosis .


he also complained of increased shortness of breath and " difficulty catching his breath ."

increased shortness of breath
difficulty catching his breath


his saturation increased to 87% on a nonrebreather .


the patient presented with abdominal pain and bloating and was found to have a large omental mass .

abdominal pain
bloating
a large omental mass


on room air , the patient 's oxygen saturation was 80% .


biopsy revealed adenocarcinoma .


a chest x-ray disclosed a left pleural effusion .


an angiogram was done which disclosed possible subsegmental pulmonary emboli of the upper lobes as well as infiltrates consistent with aspiration pneumonia .


the patient became more comfortable being seated upright with nebulizer treatments .


endoscopies were negative except for an extrinsic mass present on the stomach .


histochemical stains are consistent with hepatobiliary origin .


the patient presents with increased abdominal pain and poor oral intake as well as generalized weakness .

increased abdominal pain
poor oral intake
generalized weakness


the patient was bolused with intravenous heparin due to concern for pulmonary embolism .


while in the intensive care unit , the patient was noted to have increasing abdominal distention .


on presentation , the patient denied chest pain , shortness of breath , and cough .


octreotide was initiated in an attempt to decrease the gastric secretions .


he was noted not have an increasing left-sided pleural effusion .


due to persistent gastric secretions , an nasogastric tube was placed for decompression .


1. benign prostatic hypertrophy .


he was administered intravenous fluids and oral diet as tolerated .


2. osteoarthritis .


on the night of 05-01 , the patient complained of increased vomiting .


3. gastrointestinal adenocarcinoma ( as noted in history of present illness ) .


4. hypoxia .


5. dehydration .


the family decided to pursue comfort measures .


morphine was administered to insure patient 's comfort .


1. gastrointestinal adenocarcinoma ; primary unknown ( likely hepatobiliary ) .


6. ileus .


2. aspiration pneumonia .


3. pulmonary emboli .


he remained hemodynmically stable throughout his hospitalization and did not have an oxygen requirement upon discharge .


complex tear involving the posterior ellison and body .


the mri of your knee showed a meniscal tear .


he received lovenox 91 mg sc prior to transport and was transferred to arbour hospital for further care .


there is no pericardial effusion .


- sinus tach , normal axis hr 119 st depression v3-v5 ; s1q3t3 , p-pulmonale .

p-pulmonale
s1q3t3
st depression v3-v5
sinus tach


vs were with stable bps , tachy to 110-120 , sat 98% ra .


at springfield , ct chest was positive for saddle pe .


there is moderate pulmonary artery systolic hypertension .


you must have your inr ( blood levels ) checked on a regular basis until your inr levels remain 01-19 .


osh imaging :


immediately there after he was very short of breath , felt lightheaded again and called 911 .


no evidence of dvt in either lower limb .


please continue to take this medication as prescribed .


3. bilateral leni 's


he denies loc .


left ventricular systolic function is hyperdynamic ( ef > 75% ) .


right ventricular systolic function is borderline normal .


impression : mildly dilated right ventricle ; small , hyperdynamic left ventricle ; at least moderate pulmonary hypertension

small , hyperdynamic left ventricle
mildly dilated right ventricle
moderate pulmonary hypertension


please return to the hospital if you experience chest pain , shortness of breath , lightheadedness or dizziness .

lightheadedness
dizziness
shortness of breath
chest pain


pt was preparing lunch when suddenly felt lightheaded / faint and immediately fell to the kitchen floor face first .


the left ventricular cavity is small .


there is no mitral valve prolapse .


the right ventricular cavity is mildly dilated .


left ventricular wall thicknesses are normal .


45m w/no pmh presented to chelseahospital after a syncopal episode on the morning of admission .


the aortic valve leaflets ( 3 ) appear structurally normal with good leaflet excursion and no aortic regurgitation .


please schedule an appointment with your orthopedic surgeon to determine a plan for treatment .


syncope .


erythromycin base


there is no ventricular septal defect .


he will need to follow up with hematology for an outpatient thrombophilia work-up ( not done as inpatient as results would not change acute management of pe ).


1. ct of head without contrast :


given his history and physical exam , mr. anders presented with an injury most consistent with meniscal tear .


no evidence of acute intracranial hemorrhage or fractures .


ext : l leg/calf swollen , + johnson sign , not tense , no cord palpable , l knee w/ medial meniscus area inflammed , not warm , no crepitus , feet-2+dp pulses b/l

l leg/calf swollen
crepitus
tense
medial meniscus area inflammed
warm


#. hematocrit :


duration of his coumadin therapy to be determined by hematology , but likely to be at least 6 months in duration .


2. echo


he was anticoagulated with heparin and coumadin .


the estimated right atrial pressure is 16-20 mmhg .


his tronponin quickly trended down and he did not have ekg evidence of ischemia .


you have been started on an oral blood thinner called coumadin ( warfarin ).

coumadin ( warfarin
an oral blood thinner


mr. anders was admitted for anticoagulation and hemodynamic monitoring in the setting of saddle pulmonary embolus and left knee injury .

saddle pulmonary embolus
left knee injury


abd : soft nd/nt +bs


he has no known clotting disorder but did have trauma to leg prompting immobility and stasis .

known clotting disorder
stasis
immobility
trauma to leg


you were treated with blood thinners .


in order to facilitate therapy and to promote mobility , an mri of the knee was done .


#. l knee injury :


given no evidence of hemodynamic instability , lysis was not required .


he will also require close follow up with his primary care provider for coumadin management .


left knee meniscal tear


heent : mmm , op clear , dried blood in nasal mucosa


resp : ctabl , no crackles , no wheezing or rhonchi


#. syncope :


htn , dm


in setting of pe .


you were admitted to the hospital for a pulmonary embolism .


#. pe :


pt asymptomatic .


dropped from 42.7 to 36 in setting of anticoagulation for saddle pe and iv fluids .


cv : reg , tachy nml s1 , s2 , no m/r/g


he did have a small troponin leak , felt to be related to right heart strain in the setting of p-pulmonale related to clot burden .

p-pulmonale
clot burden
a small troponin leak
right heart strain


no active bleeding noted .


copd , prostate ca


- grandfather died of mi at age 75


an echo did not reveal any wall motion abnormalities related to ischemia .


vs : 99.4 hr 111 bp 110/64 rr16 97% 2lnc


remainder of his cardiac workup was negative .


gen : nad , pleasant speaking in full sentences


in this 2 week interval he denied having cp / chest discomfort or difficulty breathing , no cough or hemoptysis .

hemoptysis
cp
chest discomfort
difficulty breathing
cough


1. bucket handle medial meniscal tear with flipped fragment in the intercondylar notch .


no f/c/ sweats .


pt denied any bleeding or clotting disorders and has never had a clot in the past .

any bleeding or clotting disorders
a clot


2. moderate knee joint effusion with possible ganglion cyst at the insertion of the pcl .


ekg :


left knee injury .


- saddle pe , no cd or report sent


01-11 mri left knee w/o contrast


given no other risk factors or likely causes , the most likely etiology for his embolus is dvt from the left leg .


he was essentially bed bound for 3 days prior to admission , unable to ambulate .

unable to ambulate
essentially bed bound


- claritin prn


he was seen by physical therapy and will need to follow up with orthopaedics upon discharge for repeat evaluation .


he started to notice inflammation of his l calf / leg worse 2 days prior to presentation .


- flonase prn


seasonal allergies .


3. discoid lateral meniscus .


pulmonary embolus


12. protonix 20 mg p.o. b.i.d.


chest x-ray was remarkable for a questionable left lower lobe infiltrate .


7. montelukast sodium 10 mg p.o. q.h.s.


11. ativan 2 mg p.r.n.


the patient has a history of neurogenic bladder and , therefore , she required a foley catheterization .


6. buspirone 10 mg p.o. t.i.d.


10. lipitor 10 mg q.p.m.


the patient was maintained on ppi for reflux disease and known gastritis .


the patient received nebulizer treatment with oxygen saturations increasing up to 98 percent on room air .


9. singulair 10 mg q.p.m.


15. pamidronate 30 mg iv every month .


the patient was transferred on the evening of 2012-05-22 to the icu given persistent carbon dioxide retention and respiratory acidosis and the intermittent mental status changes .

persistent carbon dioxide retention
respiratory acidosis
the intermittent mental status changes


5. clonazepam 1 mg p.o. t.i.d.


4. baclofen 10 mg p.o. t.i.d.


14. albuterol nebulizer q.03-14 h. p.r.n.


asthma / copd on bipap , history of intubation .


3. levothyroxine 50 mcg p.o. q.d.


13. sucralfate 2 mg b.i.d.


11. tizanidine 8 mg p.o. q.6 h.


the patient describes chest discomfort without any significant ekg changes .

any significant ekg changes
chest discomfort


2. vitamin d .


9. protonix 40 mg p.o. q.d.


in the emergency department , the patient received zithromax , ceftriaxone , and flagyl .


the patient was maintained on albuterol nebulizer treatments and ipratropium nebulizer treatments , as this was apparently thought to be related to her chronic obstructive pulmonary disease .

albuterol nebulizer treatments
ipratropium nebulizer treatments


12. acetaminophen p.r.n.


13. prednisone taper for 3 days .


15. florinef acetate 0.1 mg p.o. q.d.


shortness of breath .


14. levofloxacin 500 mg p.o. q.d. for 10 more days .


10. albuterol sulfate solution q.05-15 h. p.r.n. for shortness of breath .


given the presence of consolidation on chest x-ray , however , and previous history of pneumonia , the patient was maintained on antibiotics of zithromax 500 mg daily and ceftriaxone .


abdominal exam :


the patient was maintained on percocet p.r.n. for pain relief .


8. atorvastatin 10 mg p.o. q.h.s.


pulmonary exam :


adrenal insufficiency .


diffuse bronchial breath sounds , no wheezes .


the patient has a history of high mcv and megaloblastic cells on smear in the setting of anemia ; question b12 deficiency , the patient also has a history of borderline low b12 levels .

megaloblastic cells
anemia
high mcv
b12 deficiency
borderline low b12 levels


coronary artery disease status post negative stress echo on 10-12 .


chronic abdominal pain .


gastritis and duodenitis .


her ph was 7.23 , pco2 73 , po2 146 on a nonrebreather .


mucomyst was also considered as a mucolytic component towards secretions .


neurogenic bladder .


chronic muscle spasms .


chronic inflammatory demyelinating polyradiculopathy .


after bipap was initiated , the patient became hypotensive down to 75/28 and bradycardiac , responding to 3 fluid boluses over the course of the night .


anemia of chronic disease .


there was no evidence of acute rib factors on her chest x-ray .


the patient had bipap initiated once she reached the unit , but did not tolerate it , becoming apneic and obstructing .


question of tyrone esophagus .


restrictive lung disease .


hyperthyroidism .


the patient was maintained on supplemental oxygen and sputum production was maximized with the help of an acapella device and respiratory therapy .

respiratory therapy
an acapella device
supplemental oxygen


depression and anxiety .


igg deficiency .


this is a 55-year-old female with multiple prior admissions for pneumonia , copd , asthma exacerbation , over 3 weeks of upper respiratory like infection unremitting with increased nebulizer treatments at home .

pneumonia
copd
asthma exacerbation
upper respiratory like infection


it was thought that the patient may have been mucous plugging during her stay in the icu .


status post cholecystectomy and appendectomy .


the patient had had abg on the floor , which prompted her to transfer to the icu .


history of syncope .


the patient saw her pcp and was known to have an oxygen saturation of 82 to 85 percent on room air .


the patient was switched to 2 liters nasal cannula and oxygen saturating at 98 to 100 percent .


the patient was started on florinef for concern of adrenal insufficiency ; however , she was hemodynamically stable that morning and was transferred back out to the floor .


the patient was on levoxyl at home as her home dose for hyperthyroidism .


the patient was maintained on iv solu - medrol 60 mg q. 8 h.


chest soreness .


hypercholesterolemia .


asthma flare and bronchitis .


adrenal insufficiency .


7. zanaflex 8 mg q.4 h.


from admission , vital signs 98.3 , blood pressure 128/74 , 68 to 112 is her heart rate , respiratory rate 24 , 100 percent on room air .

blood pressure
her heart rate
respiratory rate
vital signs


the patient was diagnosed for b12 deficiency due to her long history of poor p.o. intake .


6. buspar 10 mg t.i.d.


she is a chronically ill-appearing female , in no acute distress .


8. oxazepam 30 mg p.r.n.


methylmalonic acid levels were sent , the results are pending at the time of discharge .


4. florinef 0.1 mg p.o. q.a.m.


cardiac exam :


3. baclofen 20 mg p.o. t.i.d.


5. klonopin 2 mg t.i.d.


chronic obstructive pulmonary disease .


azmacort , clindamycin , versed , fentanyl , and morphine .

azmacort versed clindamycin fentanyl morphine


demyelinating polyradiculopathy .


left lower extremity and left upper extremity weaker at 3/5 compared to right upper extremity and right lower extremity , chronic according to the patient .


2. levoxyl 50 mcg q.d.


anxiety disorder .


the patient was also started on solu-medrol iv for active airway disease component of her shortness of breath .

her shortness of breath
active airway disease component


1. vitamin d 400 mg q.d.


chronic abdominal pain .


extremity exam :


the patient is stable without an oxygen requirement .


married with children , wheelchair bound mostly .


no edema .


1. cholecalciferol .


2019-06-19 07:20 am blood glucose - 73 urean - 20 creat - 1.1 na - 136 k - 5.0 cl - 101 hco3 - 27 angap - 13


as a result , you were started on thyroid supplements .


vitals : t 96.9 , bp 110/70 , hr 84 , rr 20 , sat 97% on 4l .


you should have follow-up blood tests by your primary care physician b 3 months .


2019-06-14 10:30 am blood alt - 34 ast - 167 * ck(cpk) - 313 * alkphos - 383 * amylase - 44 totbili - 0.7


6) if you experience any fevers , chills , chest pain , shortness of breath , dizziness or any other concerning symptoms please return to the emergency department .

fevers
chills
chest pain
shortness of breath
dizziness
any other concerning symptoms


neck : jvp not elevated .


heent : flushed cheeks .


slightly dry mm .


6. morphine 15 mg tablet sustained release sig : three ( 3 ) tablet sustained release po q12h ( every 12 hours ).


he continued to have an oxygen requirement and ct scan suggested ground glass opacities , suggestive of an underlying infectious process .

ground glass opacities
an underlying infectious process
an oxygen requirement


1) pneumonia


he later presented with increasing back pain , and metastatic disease was documented .


no s3 , s4 .


lymphovascular invasion was present .


2) acute renal failure


resp : decreased air entry and crackles at both lung bases .

decreased air entry
crackles at both lung bases


+ egophony .


no murmur or rub .


you should resume this medication starting wallace , 06-24 .


4) during your hospital stay you were also found to have low thyroid hormone levels .


5) l femur xray ( 06-18 ): predominantly sclerotic lesion with interval periosteal new bone formation involving the intertrochanteric and subtrochanteric regions .

interval periosteal new bone formation
predominantly sclerotic lesion


he is status post avastin plus sorafenib , protocol #04-393 , discontinued in the setting of


patient was also found to have abnormal tfts on sutent and was started on replacement


1. metastatic renal cell carcinoma , diagnosed in 2018-03-21 , status post left radical nephrectomy at st. margaret's center for women & infants in 03/2006 .


ongoing grade iii rash , involving the hands and feet in addition proteinuria secondary to the avastin .


his bp decreased to 100 systolic despite hydration with 2l of ns .


he has been maintained on single timlin therapy with sutent 50 mg daily as of 2018-12-21 and has completed nearly 6 cycles .


path consistent with renal cell carcinoma of chromophobe type with carter nuclear grade of 4/4 .


1) bibasilar pneumonia : patient was treated for community-acquired pneumonia .

bibasilar pneumonia
community-acquired pneumonia


2. seasonal allergies


the lung volumes are slightly increased .


he has mild renal insufficiency in the setting of sutent .


patient recorded as having no known allergies to drugs


mild posterior mitral valve prolapse with mild mitral regurgitation .

mild posterior mitral valve prolapse
mild mitral regurgitation


together with the interval development of bilateral pleural effusions , this indicates cardiac insufficiency ( or alternatively volume overload ) and an echocardiogram may be indicated for further evaluation .

bilateral pleural effusions
cardiac insufficiency
volume overload


mr. mcelveen 51 year-old male with metastatic rcc on sutent since 2018-12-21 , admitted with fever , hypoxemia , and bibasilar pneumonia .

fever
hypoxemia
bibasilar pneumonia
metastatic rcc


gen : in nad .


therapy .


3) renal insufficiency : creatinine improved from 2.1 to 1.3 at time of discharge .


in the deanna , tmax 102.8 , bp 100 - 140/60 s, hr 80 s, rr 20 s, sat 75% on ra in triage , up to 100% on nrb .


2. levofloxacin 500 mg tablet sig : one ( 1 ) tablet po q24h ( every 24 hours ) for 4 days : last dose will be nolen , 06-23 .


1) bilateral le doppler ( 06-14 ): no evidence of deep venous thrombosis in the lower extremities bilaterally .


2) cxray ( 06-14 ): new bibasilar consolidations are demonstrated accompanied by bilateral small pleural effusion .

bilateral small pleural effusion
new bibasilar consolidations


1. levothyroxine 50 mcg tablet sig : one ( 1 ) tablet po daily ( daily ).


mr. mcelveen is a 51 year-old male with metastatic rcc status post left radical nephrectomy in 2018-03-21 , status post avastin and sorafenib , most recently on sutent monotherapy since 2018-12-21 , with mild renal insufficiency , who presented from home on 2019-06-14 with shortness of breath and fever .

fever
metastatic rcc
shortness of breath
mild renal insufficiency

sorafenib
avastin
sutent monotherapy
left radical nephrectomy


medicine


1. marked interval enlargement of the cardiac silhouette .


of note , he was hospitalized at dana-farber cancer institute from 9/25-10/6 with chest pain , at which time he reportedly had cardiac enzymes , an echocardiogram and a pharmacological stress test performed .

cardiac enzymes
an echocardiogram
a pharmacological stress test


patient was instructed to restart sutent next monday .


3) when you were admitted to the hospital your sutent was stopped .


likely related to underlying malignancy as well as prerenal component given improvement with gentle hydration .

prerenal component
underlying malignancy


4. sutent 50 mg capsule sig : one ( 1 ) capsule po every other day : please restart on wallace , 06-24 .


there is no pneumothorax identified .


fluticasone propionate 110mcg 2 puff ih bid


3) ct torso ( 06-17 ):


you should continue taking this medication and your last day will be nolen , 06-23 .


recent ct scan showed destruction of l femoral neck .


it is unclear from history what these studies revealed .


2019-06-19 07:20 am blood glucose - 73 urean - 20 creat - 1.1 na - 136 k - 5.0 cl - 101 hco3 - 27 angap - 13


he reports that he felt fatigued during the week prior to the current admission .


2) you were admitted to the hospital and started on an antibiotic called levaquin for a pneumonia .


2019-06-19 07:20 am blood calcium - 8.0 * phos - 3.3 mg - 2.0


1) please take all medications as listed in the discharge instructions .


on the day of admission , he felt " congested " in his chest , and had a new fever .


he will need follow-up bloodwork as an outpatient .


he underwent an xray of the l femur which did not suggest an acute fracture .


patrick reports a mild cough for 2 days pta , non-productive .


you should take this medication every other day .


he denies a history of aspiration events or choking with food intake .


3. docusate sodium 100 mg capsule sig : one ( 1 ) capsule po bid ( 2 times a day ): take as necessary for constipation .


cxr with bibasilar consolidations .


pantoprazole 40 mg po q24h


4. new jejunal wall thickening with persistent distal ileal wall thickening and diffuse mesenteric stranding , most likely reflecting an infectious etiology .

diffuse mesenteric stranding
new jejunal wall thickening
persistent distal ileal wall thickening
an infectious etiology


docusate sodium 100 mg po bid


ipratropium bromide neb 1 neb ih q6h


5. morphine 15 mg tablet sig : one ( 1 ) tablet po q4-6h ( every 4 to 6 hours ) as needed for pain .


3) metastatic renal cell carcinoma


4) hypoxemia


he denies chills , no chest pain , no le swelling .


further ros reveals mild sob in the days preceding admission , but he tells me that he was surprised to find out about his low oxygen saturation because he did not feel that bad .


2. bilateral basilar compressive atelectasis .


medications on admission : he takes imodium and lomotil while on sutent for diarrhea .


albuterol 0.083% neb soln 1 neb ih q6h


drug toxicity would be a consideration , although somewhat less likely given the unilaterality of the findings .


heparin 5000 unit sc tid


he is also on ms contin 45 mg po q12 hours ( confirmed with wife ) and msir 15 mg every 4 hours as needed .


shortness of breath , fever


4) echo ( 06-18 ): mild symmetric left ventricular hypertrophy with preserved biventricular systolic function .


morphine sulfate 2-4 mg iv q4h : prn


levofloxacin 500 mg po q24h


ceftriaxone 1 gm iv q24h


azithromycin & ctx at time of transfer to the oncology service .


3. interval development of tree-in-eric nodular opacities and scattered ground glass opacities involving the right lung , concerning for an infectious process .


a cosyntropin stimulation test revealed cortisol 32.1 --> 36.4 .


the differential diagnosis of this is wide including viral , fungal and atypical mycobacterial infections .


he was initially placed on ceftriaxone , levaquin , and flagyl in the icu but then changed to


he is being transferred to the floor for ongoing care .


he was given levo 750 mg po x1 , and flagyl 500 mg po x1 .


2019-06-16 07:35 am blood free t4 - 0.36 *


2019-06-19 07:20 am blood wbc - 11.1 * rbc - 3.47 * hgb - 10.9 * hct - 34.1 * mcv - 98 mch - 31.3 mchc - 31.9 rdw - 16.7 * plt ct - 604 *


2019-06-16 07:35 am blood tsh - 43 *


2019-06-18 07:55 am blood caltibc - 229 ferritn - greater th trf - 176 *


2019-06-14 06:03 pm blood calcium - 8.3 * phos - 4.3 mg - 1.9


he underwent a staging ct scan torso which suggested no significant increase in tumor burden .


2019-06-14 10:30 am blood wbc - 8.0 rbc - 4.22 * hgb - 12.9 * hct - 41.7 mcv - 99 * mch - 30.5 mchc - 30.8 * rdw - 16.8 * plt ct - 797 *#


2) metastatic rcc : sutent was held on admission in light of acute infection .


2019-06-17 05:30 am blood probnp - 258 *


his respiratory status improved slowly , oxygen was weaned off , and he was discharged on course of levaquin .


he was subsquently admitted to the icu for further care .


echo was done and confirmed normal ejection fraction .


2019-06-14 10:30 am blood ck-mb - 3 ctropnt - 0.05 *


he was placed on levo and ceftriaxone .


2019-06-14 06:03 pm blood ck-mb -4 ctropnt - 0.03 *


2019-06-14 06:03 pm blood ck(cpk) - 194 *


his oxygen requirement decreased , and his overall status improved quickly .


2019-06-14 10:30 am blood plt ct - 797 *#


2019-06-14 10:30 am blood pt - 11.2 ptt - 23.9 inr(pt) - 0.9


2019-06-14 10:30 am blood glucose - 134 * urean - 39 * creat - 2.1 * na - 133 k - 7.9 * cl - 94 * hco3 - 28 angap - 19


2019-06-18 07:55 am blood pt - 11.5 inr(pt) - 1.0


2019-06-19 07:20 am blood neuts - 77.0 * bands - 5.0 lymphs - 11.0 * monos - 3.0 eos - 0 baso - 0 atyps - 1.0 * metas - 2.0 * myelos - 1.0 *

metas myelos eos monos atyps baso neuts lymphs bands


ext : without edema .


abdomen soft and non-tender .


he describes mild reflux symptoms at night .


no displaced fracture is demonstrated .


small ( 0.6 cm ) circumferential pericardial effusion , largest around the left atrium .


5. overall stability in metastatic burden .


superimposed infectious consolidation is likely .


discharge was delayed by one day to ensure patient could tolerate p.o. which patient did without difficulty .


please see original discharge summary for discharge medications .


patient was discharged to rehabilitation on 2013-06-25 .


1. left transverse mid shaft radial fracture with ulnar displacement status post left radial open reduction and internal fixation .

internal fixation
left radial open reduction


the patient 's pelvis was stable to ap and lateral compression .


white blood cell 12.9 , hemoglobin 11.5 , hematocrit 32.8 , platelet count 197,000 , sodium 141 , potassium 3.6 , chloride 110 , bicarbonate 21 , bun 20 , creatinine 0.7 , glucose 189 , pt 13.3 , inr 1.2 , ptt 30.0 , amylase 57 , arterial blood gas 7.32 , 35 , 159 , 19 , -7 .

bun
glucose
bicarbonate
creatinine
inr
ptt
pt
arterial blood gas
amylase
hematocrit
white blood cell
hemoglobin
chloride
potassium
sodium
platelet count


the patient 's right anterior tibial wound was noted to be clean , dry , and intact with sutures intact and no erythema or purulence noted .


the patient was alert and oriented times three in no apparent distress .


a 5 cm laceration was noted over the patient 's occiput on further inspection with no exposed underlying bone .

a 5 cm laceration
exposed underlying bone


on 06-30 , the patient was evaluated by occupational therapy and fitted for a left upper extremity splint .


on 06-28 , the patient was also cleared for removal of her c-spine collar and deemed stable for transfer to the orthopedic service under the direction of dr. ronda lopez .


the patient remained stable through 2010-06-29 at which point she was sent to the operating room to undergo a left radial fracture open reduction and internal fixation procedure .

a left radial fracture open reduction
internal fixation procedure


there was no erythema or purulence .


left upper extremity examination demonstrated no gross deformities , tenderness to palpation in the mid forearm , intact motor function in the median , radial , and ulnar nerve distributions , intact sensation to light touch in the median and radial nerve distributions , decreased sensation in the ulnar-nerve distribution , warm and well perfused limb with 2+ radial pulses .

left upper extremity examination
radial pulses
palpation in the mid forearm
light touch


in addition , the patient received the above-described diagnostic procedures , which demonstrated injuries limited to a posterior scalp laceration , left fractured clavicle , left fractured radius , right thigh hematoma , and right leg laceration .

right thigh hematoma
right leg laceration
injuries
a posterior scalp laceration
left fractured clavicle
left fractured radius


given the patient 's right thigh hematoma , a duplex evaluation of the right lower extremity was performed on 2010-06-28 and demonstrated no evidence of major arterial or venous injury in the level of

major arterial or venous injury
the patient 's right thigh hematoma


cardiac examination demonstrated regular rate and rhythm , no murmurs , rubs , or gallops .


the patient was also administered adaptive training for activities of daily life and advised regarding wound care .

wound care
adaptive training
activities of daily life


the patient tolerated the procedure well and demonstrated a postoperative hematocrit of 40.9 .


right lower extremity examination demonstrated mild swelling and ecchymosis of the right posterior thigh and approximately a 3 cm laceration in the lower leg , expressive of moderate amounts of standard sterile

mild swelling
ecchymosis of the right posterior thigh
a 3 cm laceration in the lower leg


examination was guaiac negative with good rectal tone .


the patient 's lung examination revealed the lungs to be clear to auscultation bilaterally , no crepitus , and a left clavicular deformity was grossly apparent on examination .

the patient 's lung examination
examination
auscultation


examination on presentation to the emergency room revealed the following :


by report , the patient was noted to be awake , but confused at the scene of the accident with no memory of the incident .


head ct demonstrated no evidence of intracranial bleeding .


in addition , the patient was also fitted with a figure-of-eight clavicular splint and instructed in its


percocet for pain as needed .


fingers were warm and well perfused with capillary refill less than 3 seconds .


the patient is to followup with an orthopedist in the united kingdom fourteen days following discharge at which point repeat x-rays of her left forearm should be obtained and her left forearm scalp and right lower leg sutures and staples may be removed .


right upper extremity examination demonstrated intact motor , sensory , and vascular function .


crystalloid and four units packed red blood cells with good response .


left lower extremity examination demonstrated no gross deformities and intact motor , sensory , and vascular examinations in all distributions .


mild swelling was noted in the left hand .


2. left midclavicular fracture managed nonoperatively .


motor , sensory , and vascular examinations were intact in all distributions .


the left forearm dressing was noted to be in place , clean , dry , and intact with no saturation .


soft , nontender , nondistended .


temperature 35.4 celsius , blood pressure 116/63 , pulse 105 , respiratory rate 18 , oxygen saturation 98% on room air .

blood pressure
oxygen saturation
respiratory rate
temperature
pulse


trauma series demonstrated no evidence of a pelvic fracture .


of note , the scalp and right lower leg lacerations were closed primarily by the trauma team on admission and on hospital day #1 were noted to be clean , dry , and intact .


the left forearm and right lower leg wound should be kept clean and dry with regular dressing changes with dry gauze once per day .


no gross deformities .


radiographic studies demonstrated an inferior displaced left midclavicular fracture , no evidence of


pneumothorax .


cervical spine imaging demonstrated no evidence of cervical spine injury .


scalp laceration should be kept clean and dry for five days following discharge after which point the patient may once wash her hair .


the left clavicle was noted to have continued ecchymosis decreased from prior examination with a minor stepoff and mild tenderness to palpation decreased from prior examinations .

mild tenderness
a minor stepoff
continued ecchymosis

palpation
prior examinations
prior examination


the patient is to maintain her figure-of-eight clavicular splint and left posterior forearm splint in place for fourteen days following discharge .

left posterior forearm splint
her figure-of-eight clavicular splint


percocet one to two tablets po q.4h. to 6h.p.r.n. pain .


4. right anterior tibial laceration .


3. occipital scalp laceration .


urinalysis was within normal limits with 6 to 10 red blood cells .


right foot and femur series demonstrated no evidence of fracture displacement .


toxicology screen was negative .


trauma ct demonstrated mild pulmonary contusions , but no pelvic fracture .

pelvic fracture
mild pulmonary contusions


left forearm and wrist series demonstrated transverse mid shaft radial fracture with ulnar displacement .

transverse mid shaft radial fracture
ulnar displacement


diagnosis peritoneum lavage times two was negative for any signs of intra-abdominal bleeding .


boston coma scale of 15 .


right tibial-fibular film series demonstrated no evidence of fracture displacement .


left humerus film series demonstrated no evidence of fracture or displacement .


she was immobilized in the c-spine collar at the scene of the accident and subsequently transported by ems to the new england sinai hospital & rehab center emergency department for further management .


nonoperative treatment was elected for the patient 's left clavicular fracture .


studies on admission revealed the following :


the patient 's head wound laceration was noted to be clean and dry with intact staples .


on postoperative day #1 , 2010-06-30 , the patient was noted to be clinically stable , tolerating oral intake , and expressive of adequate amounts of urine independent of a foley catheter .


8. ferrous sulfate 325 ( 65 ) mg tablet sig : one ( 1 ) tablet po daily ( daily ).


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


10. ipratropium bromide 0.02 % solution sig : one ( 1 ) inhalation q6h ( every 6 hours ).


14. isosorbide dinitrate 20 mg tablet sig : one ( 1 ) tablet po tid ( 3 times a day ).


5. terazosin 1 mg capsule sig : two ( 2 ) capsule po hs ( at bedtime ).


7. nimodipine 30 mg capsule sig : two ( 2 ) capsule po q4h ( every 4 hours ) for 2 weeks .


12. hydralazine 25 mg tablet sig : 1.5 tablets po tid ( 3 times a day ).


4. fluticasone-salmeterol 250-50 mcg / dose disk with device sig : one ( 1 ) disk with device inhalation bid ( 2 times a day ).


6. acetaminophen 325 mg tablet sig : 1-2 tablets po q4-6h ( every 4 to 6 hours ) as needed .


3. albuterol-ipratropium 103-18 mcg / actuation aerosol sig : 02-26 puffs inhalation q6h ( every 6 hours ) as needed .


16. glipizide 5 mg tablet sig : one ( 1 ) tablet po once a day .


explained to pt which of the meds he should no longer take that he was taking pre-admission .


2. simvastatin 40 mg tablet sig: one ( 1 ) tablet po daily ( daily ).


13. metoprolol tartrate 25 mg tablet sig : 1.5 tablets po bid ( 2 times a day ).


9. aspirin 81 mg tablet , chewable sig : one ( 1 ) tablet , chewable po daily ( daily ).


1. diltiazem hcl 240 mg capsule , sustained release sig : one ( 1 ) capsule , sustained release po daily ( daily ).


also , explained which meds are new .


11. simvastatin 40 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


patient recorded as having no known allergies to drugs


platelet count was 759,000 .


over the following days until discharge , the patient remained afebrile and on 2012-03-09 , in fact all the patient 's antibiotics were discontinued .


the patient had no further complaints and on 2012-03-10 , his white blood cell count was 2.3 , neutrophils 50% , bands 2% , lymphocytes 5% , monocytes 40% , and blasts 1% .

his white blood cell count
blasts
monocytes
lymphocytes
bands
neutrophils


as for the patient 's all and aml , the patient was started on a new chemotherapy protocol called hyper-cvad on 2012-03-06 .


after the patient began on this protocol , his white blood cell count steadily began to climb .


the patient 's hsv antibody titer was found to be negative and the patient 's acyclovir was not restarted .


the patient 's also began to climb and the percent blasts in his differential decreased significantly .


1. bactrim double strength one tablet q. monday , wednesday and friday .


the patient was also told to continue on a neutropenic diet .


the patient was discharged to home with instructions to return to the hospital on monday , 2012-03-12 , for follow-up and laboratory checks .


the patient was also told that he would have to be admitted for several days during his next cycle of cvad .


2. compazine 10 mg p.o. q 6hours p.r.n. nausea .


the patient was initially on several antibiotics included cefepime , vancomycin , ciprofloxacin , ambazone and flagyl .

several antibiotics
ambazone
ciprofloxacin
vancomycin
flagyl
cefepime


3. anzemet 100 mg p.o. once daily p.r.n. nausea .


infectious disease continued to follow and on 2012-02-29 , the patient spiked again which at that time was felt to be due to his central line and the central line was resited on the left side and the patient was started on intravenous vancomycin .

his central line
the central line
intravenous vancomycin


the patient became no longer neutropenic .


other concerns during his stay was his kidney function , due to his renal transplant in 2003 .


5. mass effect was considered , although no focal deficits were ever noted on examination and due to the fluctuating sensorium , it was determined that there was no severe underlying structural abnormality .


while the patient was in restraints , gentle hydration was initiated since p.o. intake was not adequate .


the likely cause of the delirium was a combination of surgery and intensive care unit stay in addition to poly-pharmacy .


no definite evidence for significant myocardial ischemia , although cardiac enzymes were sent and he ruled out for myocardial infarction .

significant myocardial ischemia
myocardial infarction


12. regular insulin 5 units q. a.m. and 3 to 5 units q. p.m.


a lumbar puncture was considered , although not performed due to the fact that the cerebrospinal fluid was not breached during the procedure .


the etiology for his congestive heart failure was determined likely to be diastolic dysfunction from increased heart rate as well as excess volume .

diastolic dysfunction
increased heart rate
excess volume
his congestive heart failure


he has a history of peripheral neuropathy , kidney transplantation in 2003 secondary to diabetic nephropathy , as well as throat cancer in 2004 treated with local resection and radical neck dissection on the left as well as postoperative radiation .

peripheral neuropathy
diabetic nephropathy
throat cancer

kidney transplantation
postoperative radiation
local resection
radical neck dissection on the left


he was febrile in the intensive care unit to 101.0 f. ; yet , chest x-ray , blood cultures , urinalysis and urine cultures were all negative for sources .

urine cultures
urinalysis
chest x-ray
blood cultures


the only other complaints from mr. mackey during his stay were :


this was attributed to postoperative swelling and changes from his diskectomy performed 2010-08-27 .


rpr evaluating for possible neurologic syphilis was also checked .


mr. mackey also had signs and symptoms consistent with cervical myelopathy ; a cervical mri scan showed very impressive disc herniations at c5-c6 , less so at c4-c5 , with clear cut cord compression , particularly on the right side c5-c6 .

clear cut cord compression
cervical myelopathy
impressive disc herniations at c5-c6
signs and symptoms


his respiratory rate was 30 on face mask .


tsh was within normal limits as was b12 and folate .


he responded to intravenous lasix with 3.2 liters of urine output as well as marked clinical improvement .


there were no electrolytes or mineral abnormalities that could explain his delirium .

his delirium
electrolytes or mineral abnormalities


therefore , he was admitted for c4-c5 and c5-c6 anterior diskectomy with autologous bone graft and instrumented fusion .

autologous bone graft
c4-c5 and c5-c6 anterior diskectomy
instrumented fusion


the patient was found out of bed but no signs of head trauma , no loss of consciousness .


interoperatively , he was positive two liters with a stable blood pressure and heart rate , although requiring some neo-synephrine interoperatively .


the restraints were weaned off overnight although he became acutely agitated and they were replaced early on 08-31 .


liver function tests were checked , only total bilirubin was slightly elevated at 1.6 .


he was awake , alert , uncomfortable secondary to incisional tenderness at neck site as well as right iliac graft site .

uncomfortable
incisional tenderness
neck site
right iliac graft site


throughout his stay , chem-10 was monitored .


an eeg was also considered to rule out non-convulsive status epilepticus , although again this did not seem to be a likely cause .


postoperative physical examination demonstrated that he was afebrile at 97 degrees ; blood pressure 145/80 ; pulse 60 ; respiratory rate 10 ; 100% on a non-rebreather .

blood pressure
respiratory rate
postoperative physical examination
pulse


no acute intracranial hemorrhages or midline shifts were noted , although a soft tissue mass was noted at the level of c2 .

midline shifts
acute intracranial hemorrhages
a soft tissue mass


the wounds were clean , dry and intact , and flat .


the assay was nonreactive .


a head and neck ct scan , non-contrast , were ordered though to evaluate for such processes .


soreness at his operative sites , for which he was given p.r.n. tylenol once his delirium had resolved .

his operative sites
soreness
his delirium


haldol as well as the restraints were not required after the morning of the 23rd .


intramuscular as well as intravenous haldol were ordered p.r.n. for emergency use should he become acutely agitated .


the patient continued to do well and did not require restraints after that event .


he was also put on lopressor 150 mg twice a day .


on the evening of the 22nd , the patient became acutely agitated , threatening to leave , and also threatening to harm those nurses and physicians that were attempting to prevent him from leaving .


later in the morning on 08-31 , the patient was more oriented and alert , and asked to have the restraints removed .


restraints , for the safety of both the patient and the staff of the hospital .


he was given lasix to continue to diurese the excess volume .


each progressive day, mr. donald delirium abated with return to baseline mental status early on 09-01 .


his immunosuppressive therapy was continued throughout his stay ; his creatinine remained approximately 2.3 to 2.4 ; he has a baseline renal insufficiency .


3. pyelonephritis .


7. zithropren 50 mg q. day .


the patient became agitated with both tent and bi-pap machine , although continued to saturate well .


5. cyclosporin microemulsion .


also in the intensive care unit , o2 saturation was closely monitored .


mr. robert mackey is a 49 year old gentleman with a 22 year history of diabetes mellitus .


4. nitroglycerin sublingual 0.3 mg p.r.n.


with this in mind , when obtaining a ct scan it was determined that contrast would not be the best option .


he was transferred to medicine the morning of 2010-08-30 , for continued medical management post surgery .


5. right coronary artery stent in 2008 ; ejection fraction 60 to 65% .


10. prilosec 20 mg q. day .


on the day of transfer , the patient was noted to be confused with waxing and waning sensorium ; thus , a delirium work-up was initiated looking for precipitants .


8. prednisone 10 mg q. day .


1. when his o2 saturation was monitored , his pulse oximetry remained in the 90s during his stay .


6. neoral 100 mg twice a day .


2. his non-essential medications that may have been contributing to his change in mental status were discontinued ; those included temocillin , nortriptyline , haldol , lorazepam , venlafaxine , bupropion , and gabapentin .

his non-essential medications
temocillin
nortriptyline
lorazepam
haldol
venlafaxine
bupropion
gabapentin


7. benign prostatic hypertrophy status post transurethral resection of the prostate ; self catheterization .

transurethral resection of the prostate
self catheterization


11. nph 30 units q. a.m. , 5 to 6 units q. p.m.


9. minoxidil 10 mg twice a day .


while in the pacu , anesthesia was called because the patient became dyspneic and tachypneic and his sao2 dropped to 89% .


12. cerebral aneurysm .


as for his diabetes mellitus , the mahoney team provided updated recommendations each day , adjusting for the changing p.o. intake .


6. trauma was also considered .


4. creatinine 2.2 to 2.5 .


nortriptyline 10 mg q. h.s. ; flomax 0.4 mg q. h.s. ; neurontin 600 mg three times a day .


3. he was also discharged home with visiting nurse association for physical therapy evaluation of home safety .


13. wellbutrin 100 mg q. day .


gentamicin , and ibuprofen .


15. nitroglycerin sr 2.5 mg twice a day .


6. type 1 diabetes mellitus with triopathy , retinopathy , neuropathy , nephropathy .

neuropathy
nephropathy
retinopathy
triopathy
type 1 diabetes mellitus


he was instructed to hold the following three medications that he took prior to admission :


14. zocor 60 mg q. day .


in addition , his cyclosporin levels were checked .


1. c4-c5 , c5-c6 , anterior microdiscectomy and fusion with right iliac bone graft .


3. hypo or hyperglycemia :


in addition , he also complained of difficulty with swallowing , necessitating only soft and liquid diet .


finger sticks were in the 150 s when acutely agitated , therefore , it was not determined that glucose levels were contributory .


mahoney had been following with their appreciated recommendations on glucose control .


11. throat cancer status post right neck dissection and xrt in 2004 .


1. end-stage renal disease secondary to type 1 diabetes mellitus ; status post renal transplant in 2003 .

end-stage renal disease
type 1 diabetes mellitus


13. left prosthetic cmed ccu .


8. hypertension .


9. hypercholesterolemia .


4. infectious causes were evaluated .


3. metoprolol 100 mg twice a day .


10. hepatitis b .


2. furosemide 20 mg q.o.d.


2. history of multiple urinary tract infections .


1. venlafaxine xr 75 mg q. a.m.


a ct scan with po contrast showed dilation of intrahepatic common bile duct which is improved from previous studies .

a ct scan with po contrast
previous studies


rectal exam showed no masses and is guaiac negative .


his creatinine levels trended toward normal and the fractional excretion of sodium also increased indicating a resolution of the prerenal kidney failure .

his creatinine levels
the fractional excretion of sodium


he was given zosyn for empiric treatment .


the patient 's postoperative course was notable for an elevation in white blood cell count peaking at 30.0 on postoperative day number two .


at the time an 8 caucasian catheter was placed in the common hepatic/bioduct for external drainage .

an 8 caucasian catheter
external drainage


the somatostatin and the midodrine were discontinued and the regimen of lasix and spironolactone was started for diuresis .

spironolactone
diuresis
the midodrine
lasix
the somatostatin


alt 106 , ast 149 , alkaline phosphatase 242 .


on exploration of the abdomen revealed significant nodularity of the liver indicating of advanced cirrhosis .

advanced cirrhosis
significant nodularity of the liver


while in the hospital , the patient received initial work-up including echocardiogram , electrocardiogram and serology studies to be listed for liver transplant .

initial work-up
electrocardiogram
serology studies
echocardiogram


and it is noted there was nodularity in the common bile duct which is worrisome for cholangiocarcinoma .

cholangiocarcinoma
nodularity in the common bile duct


revealed greater than 24,000 white blood cell count in the ascites which is consistent with svt .


he has a picc line in place for continued treatment with rocephin and he will have a visiting nurse to help him to administer these medications .


somatostatin and midodrine were also given for this condition and he also received packed red blood cells .

midodrine
packed red blood cells
somatostatin


nodularities in the common bile duct visualized by endoscopic retrograde cholangiopancreatography was also worrisome for cholangiocarcinoma and the patient was admitted to the blue general surgery service for possible surgical interventions .

nodularities in the common bile duct
cholangiocarcinoma


fractional excretion of sodium was less than 1% suggesting a prerenal etiology .


the patient tolerated the procedure well and he was sent to the floor in stable condition .


mr. cordano is a 58-year-old gentlemen with a past medical history significant for primary sclerosing cholangitis who presented with a chief complaint of endoscopic retrograde cholangiopancreatography endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiogram .


cholangiogram on postoperative day number two showed no evidence of leakage at the anastomosis site .


the head is normocephalic , atraumatic and eyes are icteric .


gram stain and culture of the ascites failed to identify any organism .


a white blood cell count of 14.2 , hematocrit of 35.3 , platelet count of 449,000 .

hematocrit
platelet count
a white blood cell count


chest x-ray and sputum culture obtained at the time were negative and the patient was treated with 100% nonrebreather which improved his oxygenation .

his oxygenation
chest x-ray
sputum culture


an endoscopic retrograde cholangiopancreatography also demonstrated similar findings


therefore , the patient was taken to the operating room on 2009-08-24 for a whipple procedure versus hepaticojejunostomy .


the endoscopic retrograde cholangiopancreatography also showed the presence proximal common bile duct .


sodium of 130 , potassium 3.5 , chloride 93 , bicarbonate 28 , bun 15 , creatinine 1.1, prothrombin time 14.1 , partial thrombin time 29.7 .

chloride
sodium
potassium
creatinine
bicarbonate
bun
prothrombin time
partial thrombin time


region nodularity , which is identified previously by endoscopic retrograde cholangiopancreatography , and regional lymph nodes were all sent to pathology .


they were all negative for malignancy and therefore a hepaticojejunostomy


on postoperative day number ten , the patient returned to the floor with improved renal function and without oxygen requirement .


inr 1.4 .


the patient is a jaundiced looking gentlemen in no acute distress .


he was weaned from oxygen requirement and was continued on normal saline boluses and


status post placement of percutaneous transhepatic biliary drainage with placement of 8 caucasian nephrostomy catheter in the common bile duct .


on postoperative day number eight , the patient 's oxygen saturation dropped to 85% on room air and he was transferred to the surgical intensive care unit for fluid management .


it is also noted that there was splenomegaly .


he also had significant lower extremity and scrotum edema .


mr. cordano was admitted on 2009-08-17 for a replacement of transhepatic biliary drainage catheter .


at that time , cholangiogram confirmed that there was a distal stricture of the common bile duct .


2. furosemide 10 mg q.d.


1. rocephin 1 gram q.d.


the neck is supple with no lymphadenopathy .


2. ambien 5 mg q.h.s.


the abdomen was soft , nontender , no masses and nondistended .


the chest is clear to auscultation bilaterally .


while he is in the surgical intensive care unit , paracentesis was performed and it


chest x-ray revealed minimal left base atelectasis and elevation of left hemidiaphragm .

minimal left base atelectasis
elevation of left hemidiaphragm


neurological exam was grossly intact .


no known drug allergies .


ulcerative colitis , primary sclerosing cholangitis .

ulcerative colitis
primary sclerosing cholangitis


a chest x-ray was also negative for any pneumonia .


postoperatively , mr. cordano also suffered from low urine output ranges between 25 to 30 cc per hour .


intravenous albumin for treatment of prerenal azotemia .


he was given unasyn for empiric antibiotic treatment .


1. ursodiol 600 mg t.i.d.


total bilirubin 10.1 , amylase 90 and lipase 112 .


at the time , blood , urine and bile was sent for culture , which were all negative .


there is no murmurs .


psc , status post hepaticojejunostomy .


at the same time , the patient also developed distentions of the abdomen consistent with accumulation of ascitic fluid .

distentions of the abdomen
accumulation of ascitic fluid


3. spironolactone 100 mg q.d.


the sodium creatinine peaked at 2.0 and the patient was treated with boluses of intravenous fluid and intravenous albumin infusion was also administered .

boluses of intravenous fluid
intravenous albumin infusion


4. ursodiol 600 mg po t.i.d.


there is no hepatosplenomegaly .


the most recent percutaneous transluminal coronary angioplasty was done in 2009-07-25 .


he responded well to this regimen and made adequate urine output .


cardiopulmonary bypass time was 234 minutes .


aspirin 81 mg p.o. q. day .


the patient has gastroesophageal reflux disease , for which he has been receiving zantac as an inpatient .


a psychiatric consult was also obtained due to his mental status and confusion postoperatively but his psychiatric issues are mostly related to his neurologic insults and he has no distinctive psychiatric disorder , except for perhaps postoperative delirium .

distinctive psychiatric disorder
postoperative delirium
confusion
his neurologic insults
his psychiatric issues


metoprolol 75 mg p.o. twice a day .


nor does he have any history of stroke like symptoms .


in addition , over the last couple of days prior to discharge , the patient did appear a little bit icteric .


milrinone was continued until postoperative day number three , at which point he was having good enough cardiac output that he did not need these drips to help maintain his blood pressure anymore .


liver function tests were obtained and they were slightly elevated liver function tests and alt was 44 , ast was 34 ; alkaline phosphatase was 199 , within normal limits .

liver function tests
alt
ast
alkaline phosphatase


briefly , the patient was taken to the operating room to repair his critical aortic stenosis , his coronary artery disease and his significantly dilated ascending aortic aneurysm .


he has a recent history of dyspnea on exertion on exertional chest pain which has increased over the last several weeks and is relieved by sublingual nitroglycerin .


finally , a super coronary arch graft was implanted .


the left internal mammary artery was connected to the proximal left anterior descending and saphenous vein grafts were connected to the posterior descending artery , diagonal branch , obtuse marginal and distal left anterior descending .


the patient remained intubated until postoperative day number five .


the procedure was an aortic valve replacement with a tissue valve , a coronary artery bypass graft procedure where five grafts were performed .


this is a 56 year old man with history of hypercholesterolemia and type ii diabetes mellitus .

type ii diabetes mellitus
hypercholesterolemia


the levophed drip was continued until postoperative day number one .


he has no bleeding or clotting problems .


he does not have wheezing , claudication or gastrointestinal bleeding .

claudication
gastrointestinal bleeding
wheezing


plavix 75 mg p.o. q. day .


the patient did receive a significant amount of diuresis postoperatively and is well below his baseline with weight , most likely because of his inability to eat because of his stroke .


he was admitted to the cardiac surgery service for an elected bental procedure with homograft and coronary artery bypass graft .

homograft
coronary artery bypass graft
an elected bental procedure


recent pneumonia .


once consent and preoperative evaluation was complete , he was taken to the operating room .


total bilirubin was 2.8 .


as the patient became more awake , he still remained somewhat confused and a little bit out of it .

somewhat confused
a little bit out of it


heparin 5000 units subcutaneous twice a day .


on physical examination , the patient is afebrile .


amylase was 108 and lipase was 213 .


this was seen on the cat scan on postoperative day number one , 12-31 .


no known drug allergies .


we will put him back on his nexium .


hypercholesterolemia .


humalog max 75/25 , 20 units subcutaneous once a day in the morning .


metformin 1000 mg extended release p.o. q. day .


cardiovascularly , the patient did extremely well following the surgery .


at the time of discharge , mr. norman hematocrit is at 40.7 .


chronic blood loss anemia and chronic rbc transfusion .


please stay on top of the sliding scale so that the patient can keep a euglycemic level .


perioperative stroke .


his atrioventricular valve gradient was 27 with an av surface area of .91 .

his atrioventricular valve gradient
an av surface area


because of his confusion , a neurology consult was obtained and subsequent radiographic imaging revealed chronic appearing infarcts in the right occipital lobe as well as both cerebellar hemispheres , suggestive of more chronic infarcts , as well as an area in the left corona radiata , adjacent to the left lateral ventricle which may or may not be an acute infarct .


in addition , mr. douglass is given trazodone to help him sleep at night .


weight is 82 kilograms .


this was a .................... graft .


he is going out on a cardiac healthy , diabetic diet , as tolerated with boost supplements .

boost supplements
a cardiac healthy , diabetic diet


the patient tolerated the procedure well and was transferred to the unit , intubated on milrinone , levophed and propofol drips .

the procedure
milrinone
propofol drips
levophed
intubated


no bruits appreciated .


urinary tract infection .


the patient , during this admission , required transfusion of three units of packed red blood cells to maintain adequate hematocrit .


his oxygen saturations remained good and he did not require supplemental oxygen more than a couple of days after his extubation .


as mr. douglass has improved from his initial stroke , he has become more lucid


cardiac catheterization at the end of october revealed a dilated aortic root to 4.4 cm and 80% stenosis of the mid left anterior descending at the bifurcation involving the diagonal branch , 70% stenoses of the left circumflex and oblique marginal artery and 90% stenosis of the posterior descending artery .


his aorta was cross clamped for 168 minutes .


over his postoperative course , mr. douglass has gradually been able to utilize more and more of his right side and with the assistance of physical therapy and occupational therapy , he has 4 to 5 + strength in his right hand and arm and about 4 + strength in his right leg .


in addition , he was noted to have a right sided hemiplegia .


on 01-08 , the patient 's central venous line was discontinued .


review of systems shows that the patient denies any orthopnea , paroxysmal nocturnal dyspnea .

paroxysmal nocturnal dyspnea
any orthopnea


head and neck examination :


type ii diabetes .


he was started on oct. 25 for this bug .


juanita does not feel any palpitations .


captopril 12.5 mg p.o. three times a day .


the catheterization tip also grew out serratia .


gastroesophageal reflux disease .


on the 16th , a urine culture was obtained and did grow out greater than 100,000 colonies of e. coli which was intermittently resistant to ciprofloxacin .


blood pressure 126/66 .


coronary artery disease , status post coronary artery bypass graft .


no hepatosplenomegaly and no cva tenderness .


in addition , the patient did have slightly elevated blood sugars over the last couple of days and has required an insulin sliding scale and basal insulin to maintain his blood sugars at a more appropriate level .


aortic arch aneurysm , status post aortic arch graft .


acute postoperative delirium .


lipitor 10 mg once a day .


please continue mr. david montero for one month to fight his blood borne infection , to prevent seeding of his aortic graft and continue bactrim for ten days after discharge to treat the e. coli in his urine .

the e. coli in his urine
his blood borne infection


a right upper quadrant ultrasound did not reveal any gallstones or common bile duct dilatation indicative of cholecystitis or cholelithiasis .

cholecystitis
cholelithiasis
common bile duct dilatation
any gallstones


the major neurologic event of this hospital course was that the patient was slow to awake after his propofol drip was discontinued .

slow to awake
the major neurologic event


he was started on bactrim for that .


critical aortic stenosis , status post aortic valve replacement .


after an extended stay for hemodynamic monitoring and pressor support to maintain his perfusion .


and is less of an aspiration risk .


one aspirin a day .


3/6 systolic ejection murmur throughout his precordium .


his abdomen is soft , nontender , nondistended .


declared him at first an aspiration risk .


after that , the patient had no major problems with his lungs .


nexium 40 mg a day .


lungs are clear to auscultation bilaterally .


trazodone 25 mg p.o. q h.s. as needed for sleep .


colace 100 mg p.o. twice a day .


he had pharmacologic circulatory arrest for 18 minutes .


levofloxacin 500 mg p.o. q. day .


no varicosities noted .


the patient remained intubated until postoperative day number five .


he has remained without any chest pain following this procedure and his sternal wound is clean , dry and intact at the end of the procedure .


the patient had positive blood and urine cultures on 01-05 for history of methicillin resistant staphylococcus aureus , which was pan sensitive .


hold for loose stools .


bactrim ds tabs , one tablet p.o. q. day for ten days .


kcl 20 mg p.o. q. day for one week .


in addition , he has hypertension , for which he receives metoprolol and he has hypercholesterolemia , for which he receives nothing at this time .


extremities are warm , well perfused , no cyanosis , clubbing or


lasix 20 mg p.o. q. day for one week .


carvedilol 6.125 mg a day .


glucophage 25 mg once a day .


nexium 40 mg p.o. q. day .


on 2016-06-26 , he had a positive exercise tolerance test .


recent weight loss associated with the pneumonia .


edema .


2014-02-21 12:20 pm blood alt - 17 ast - 27 alkphos - 119 * amylase - 27 totbili - 0.9


ctab , mildly decreased breath sounds b/l


gastrointestinal : her initial ct scan showed dilated turner colon , wall thickening and pneumatosis see pertinent results .

pneumatosis
wall thickening
dilated turner colon


abd soft , nt/nd , + bs , no masses , ostomy in rlq pink , with stool


she was transferred to arbour hospital on 2015-02-21 for bowel obstruction , ischemia and worsening abdominal distention and pain .

pain
worsening abdominal distention
ischemia
bowel obstruction


s/p exploratory laparotomy , resection of small intestine with primary anastomosis , sigmoid colectomy , repair of colovesicular fistula

primary anastomosis
resection of small intestine
sigmoid colectomy
repair


she was initially treated nonoperatively with iv fluids , antibiotics , serial exams and ngt decompression .


afebrile , vss


2014-02-21 12:20 pm blood ck-mb - 7 ctropnt -< 0.01


a&o x 3 , nad


2014-03-09 11:29 am blood ck-mb - 35 * mb indx - 25.5 * ctropnt - 0.45 *


cad s/p mi , htn , dmii


on hd#5 flexible sigmoidoscopy was performed for colonic decompression .


03-07 wound swab : vre


please call the surgeon or return to the emergency department if you develop chest pain , shortness of breath , fever greater than 101.5 , foul smelling or colorful drainage from your incisions , redness or swelling , severe abdominal pain or distention , persistent nausea or vomiting , inability to eat or drink , or any

inability to eat or drink
severe abdominal pain
redness
swelling
distention
shortness of breath
chest pain
fever greater than 101.5
vomiting
foul smelling or colorful drainage
persistent nausea
your incisions


on hd#6 , colonscopy was performed for decompression , and revealed pseudomembrane and friable colonic tissue .


other symptoms which are concerning to you .


2014-03-09 07:52 pm blood ck-mb - notdone ctropnt - 0.55 *


2014-03-19 01:33 pm blood ck-mb - notdone ctropnt - 0.17 *


her abdomen remained tender and distended despite attempted decompression .


2014-03-21 09:58 am blood ck-mb - notdone ctropnt - 0.06 *


she recieved further resection of remaining colon , repair of a leak from relaford pouch and repair of colovesicular fistula .

colovesicular fistula
a leak from relaford pouch

repair
further resection of remaining colon
repair


she was treated in iuc for unstable angina with nitroglycerin .


16. miconazole nitrate 2 % cream sig : one ( 1 ) appl topical bid ( 2 times a day ).


1. markedly dilated colon throughout ascending , transverse , and descending colon with air-fluid levels , overall unchanged since prior study performed on the same day with pneumatosis in the ascending colon .

pneumatosis in the ascending colon
markedly dilated colon
air-fluid levels


15. miconazole nitrate 2 % powder sig : one ( 1 ) appl topical bid ( 2 times a day ) as needed .


it was recommended to maximize her medical treatment with beta blockers , aspirin , a statin and an ace inhibitor .

beta blockers
aspirin
a statin
an ace inhibitor
her medical treatment


nutrition : she was held npo at admission , and initiated on tpn by hd#3 .


17. ibuprofen 100 mg/5 ml suspension sig : twenty ( 20 ) ml po q8h ( every 8 hours ) as needed .


leave white strips above your incisions in place , allow them to fall off on their own .


sigmoid diverticulosis with focal narrowing of the sigmoid colon just distal to the dilatation with wall thickening , due to diverticulitis .

wall thickening
focal narrowing of the sigmoid colon
the dilatation
diverticulitis
sigmoid diverticulosis


medications : resume your home medications .


2014-03-19 07:13 am blood ck-mb - 3 ctropnt - 0.19 *


respiratory : she was intubated briefly post-op subtotal colectomy and again for several days after second surgery .

intubated
subtotal colectomy
second surgery


s/p subtotal colectomy , ileostomy , gastrostomy tube

subtotal colectomy
gastrostomy tube
ileostomy


required diuresis of > 9 l while in the icu , after 2nd surgery .


4. bilateral renal cysts .


hurtado colon


18. debrox 6.5 % drops sig : five ( 5 ) drop otic bid ( 2 times a day ) for 5 days : both ears .


3. small amount of ascites , somewhat increased anterior to the liver .


13. potassium chloride 20 meq tab sust . rel . particle / crystal sig : one ( 1 ) tab sust . rel . particle / crystal po once a day .


ct abd 02-21 :


5. heavy calcification of the aorta and sma and its branches .


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


11. oxycodone 5 mg tablet sig : one ( 1 ) tablet po q4-6h ( every 4 to 6 hours ) as needed for pain .


due to atherosclerosis , assessment of the intraluminal process of these branches is limited .


2. completion sigmoid colectomy , repair of colovesicular fistula , small bowel repair

repair
small bowel repair
completion sigmoid colectomy


genitourinary : she had a foley catheter from the time of admission .


ms crossman is an 84 year old female with complaints of abdominal pain , diarrhea , nausea and vomiting x 1 week , who presented to an outside hospital .


her incision has remained clean , dry , intact , with staples removed on pod# 27/18 .


sulfa ( sulfonamides )


le trace edema


her foley was subsequently dc 'd .


2014-02-21 12:20 pm blood wbc - 10.2 rbc - 5.32 hgb - 14.9 hct - 43.4 mcv - 82 mch - 28.0 mchc - 34.4 rdw - 16.0 * plt ct - 204

blood
plt ct
mchc
hct
mcv
mch
rbc
hgb
rdw
wbc


pod# 23/14 she recieved a cystoscopy which revealed no leak .


the other daughter was recently in a car accident and underwent surgery at saint vincent hospital .


1. subtotal colectomy , end ileostomy , hartmann's pouch , g-tube

end ileostomy
hartmann's pouch
subtotal colectomy
g-tube


see pt note for further assessment and discussion .


musculoskeletal : has suffered significant deconditioning since admission , but has consisitently recieved pt .


by pod# 05-29 she was having high residuals on tf s, so tpn was reinitiated .


nausea , vomiting , abdominal pain , distention .

nausea
vomiting
distention
abdominal pain


post-operatively she began on tf s, and the tpn was weaned down .


2014-02-21 12:20 pm blood glucose - 345 * urean - 34 * creat - 1.0 na - 137 k - 4.3 cl - 99 hco3 - 24 angap - 18

k cl urean creat hco3 angap na blood glucose


she was taken to the or for subtotal colectomy , g tube and ileostomy due to unresponsiveness to non-operative treatment .

g tube
subtotal colectomy
ileostomy
non-operative treatment


g-tube in place


she was taken to the or for exploration and drainage .


after her 2nd surgery she returned to the icu and improved steadily .


pain : her pain was controlled with iv pain medicines while in icu .


2014-02-21 12:20 pm blood pt - 12.9 ptt - 32.5 inr(pt) - 1.1


she remained on iv antibiotics x 14 days and required pressors for the first few days post-op .


this area can be a leading point of obstruction .


abdomen remained soft and nontender .


2. left lower quadrant thick-walled peripherally enhancing fluid collection , which appears to communicate with the sutured end of the proximal sigmoid colon via a small collection of extraluminal gas .


she has been adequately controlled with tylenol , motrin & oxycodone by mouth , per recommendations by geriatrics .


on pod#8 a ct scan was obtained which revealed an abcess with a colovesicular fistula .


2014-03-10 05:25 pm blood ctropnt - 0.42 *


her hct dropped and she recieved 1 unit prbcs .


she developed additional abdominal tenderness and distention .

distention
additional abdominal tenderness


2014-03-09 02:59 am blood ctropnt - 0.21 *


she was followed by cape cod hospital clinic for treatment of persistent hyperglycemia .


at time of discharge she is tolerating a regular diet with tf 's at goal .


tf goals were achieved and tpn dc 'ed.


ileostomy remains pink and intact , draining green-brown soft stool .


pod# 15/6 , she resumed tf 's and tpn was tapered again .


recieved nebulizer treatments post-op in the icu , after successfully extubated .


continues to have trace lower extremity edema , and recieves lasix po .


2014-03-11 02:00 am blood ctropnt - 0.45 *


tf 's were dc 'ed prior to second surgery .


unstable angina


4. status post ileostomy without evidence of small-bowel obstruction .


diverticulitis


3. moderate intraabdominal ascites .


19. trazodone 50 mg tablet sig : 1 / 2-1 tablet po hs ( at bedtime ).


an underlying mass lesion or cancer cannot be excluded in this area , and further clinical investigation is recommended .


14. glargine sig : twenty two ( 22 ) units at bedtime .


norvasc


in the correct clincial setting , this could be consistent with an abscess .


2. limited evaluation for known sigmoid-vesicle fistula .


pod# 22/15 ms crossman was transferred to 3 north where she continued to progress well with pt , increasing po intake , tolerating tf s, and weaning from nasal cannula oxygen .


2014-02-21 12:20 pm blood lipase - 11


you should take a stool softener , colace 100 mg twice daily as needed for constipation .


required restraints to prevent dc of pertinent therapies while in the icu .


intermitent delirium throughout admission .


you will be given pain medication which may make you drowsy .


neuro : developed confusion during her first 5 days in the icu .


if there is clear drainage from your incisions , cover with a dry dressing .


03-21 vcug - no leak


she has remained stable with no acute events .


6. diverticulosis within the right remnant sigmoid colon .


troponins remained mildly elevated as high as 0.6 throughout her admission , and most recent result now 0.1 .


lasix


insulin


isosorbide


she recieved serial enzymes and ekgs .


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


atenolol


cardiovascular : complained of chest pain during first few days of admission , a cardiology consult was obtained .


5. aspirin 81 mg tablet , chewable sig : one ( 1 ) tablet , chewable po daily ( daily ).


3. polyvinyl alcohol - povidone 1.4-0.6 % dropperette sig : 02-25 drops ophthalmic prn ( as needed ).


cta/ct abd 03-07 :


2. acetaminophen 325 mg tablet sig : 1-2 tablets po q4-6h ( every 4 to 6 hours ) as needed .


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


10. albuterol 90 mcg / actuation aerosol sig : 1-2 puffs inhalation q6h ( every 6 hours ) as needed .


9. ipratropium bromide 17 mcg / actuation aerosol sig : two ( 2 ) puff inhalation q4-6h ( every 4 to 6 hours ) as needed .


7. lisinopril 5 mg tablet sig : 0.5 tablet po daily ( daily ).


8. furosemide 40 mg tablet sig : 1.5 tablets po bid ( 2 times a day ).


5. distended gallbladder .


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


patient is an insulin dependent diabetic .


small bilateral pleural effusions with compressive atelectasis .

small bilateral pleural effusions
compressive atelectasis


1. no evidence of pulmonary embolism .


a/p : 48yo man with h/o hcv , bipolar do , h/o suicide attempts , a/w overdose of inderal , klonopin , geodon , s/t jackson stay with intubation for airway protection , with question of l retrocardiac infiltrate , now doing well .

l retrocardiac infiltrate
hcv
overdose
bipolar do

airway protection
intubation
inderal
geodon
klonopin


cv : rrr , nl s1 s2 , no m/g/r


mr. vazquez is a 48 year old man with a history of hepatitis c , bipolar disorder with suicide attempts in the past , recent cmed admit earlier in 4/05 who was found alert approximately one hour after taking an unspecified number of pills .


2012-06-07 09:55 pm blood wbc - 8.9 rbc - 4.94 hgb - 15.8 hct - 45.3 mcv - 92 mch - 31.9 mchc - 34.8 rdw - 12.4 plt ct - 175

mcv
hct
hgb
rbc
plt ct
mch
wbc
blood
mchc
rdw


neck : supple , no lad , no jvd


reports that he has suffered from anxiety since childhood and needed to drop out of college .


overdose


- watch for bzd withdrawal , agitation


2012-06-07 09:55 pm blood neuts - 49.9 * lymphs - 42.4 * monos - 5.5 eos - 1.6 baso - 0.6


abd : normal size , nd , no scars , nl bs , soft , nt , palp liver


patient recorded as having no known allergies to drugs


bipolar disorder :


lungs : ? decreased bs over left middle lung , otherwise cta


- monitor on tele overnight


the patient was reportedly alert at scene , and then became unresponsive in route to the hospital .


ext : no c/c/e , no edema