4. history of orthostasis with tilt table testing done in the past .


8. phenazopyridine hcl 100 mg tablet sig : one ( 1 ) tablet po tid ( 3 times a day ) for 3 days .


ext : no c/c/e


7. hyoscyamine sulfate 0.125 mg tablet sig : one ( 1 ) tablet po qid ( 4 times a day ) .


6. atenolol 100 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


1. coronary artery disease ( s/p stents to lad and 3rd om )


5. aluminum-magnesium hydroxide 225-200 mg/5 ml suspension sig : 15-30 mls po qid ( 4 times a day ) as needed for indigestion .


7. pericarditis .


glucose - 94 urea n - 22* creat - 1.4* sodium - 142


potassium - 5.9* chloride - 108 total co2 - 23 anion gap - 17


rrr , no m/r/g


leave the steri strips on until they begin to peel , then you may remove them. staples and stitches will remain until your follow-up appointment .


father had mi at 42


you may remove your dressings 2 days after your surgery if they were not removed in the hospital .


continue taking your home medications unless otherwise contraindicated and follow up with pcp .


mother died of mi at 76


nad


calcium - 9.7 phosphate - 3.9 magnesium - 1.9


pt - 12.2 ptt - 23.8 inr ( pt ) - 0.9


he has had symptoms of dribbling , stress incontinence , hematuria , but has no dysuria .

dribbling
symptoms
stress incontinence
hematuria
dysuria


ecg :


nsr at 62 , nl axis , nl intervals , q waves in iii , avr , v1 .


you may take showers ( no baths ) after your dressings have been removed from your wounds .


9. hypercholesterolemia .


8. hypertension .


if you experience clear drainage from your wounds , cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days .


10. gastrointestinal bleed


5. status post transurethral resection of prostate times two ( in 2007 and 1998 ) .


6. interstitial cystitis .


no complications .


estimated blood loss of 300 cc .


the percutaneous endoscopic gastrostomy was unsuccessful , and the procedure was converted to an open gastrostomy tube which then proceeded without complications .

the procedure
an open gastrostomy tube
the percutaneous endoscopic gastrostomy


the flap was pink with a strong doppler signal .


he was sedated and ventilated by his tracheostomy 6 cuff shiley tube .


the plastic team then took over for reconstruction consisting of radial forearm free flap to floor of mouth .


he was placed on unasyn 3 grams iv q.6h.


frozen section sent to pathology revealing invasive squamous cell carcinoma .


total intravenous fluids of 7300 cc .


3. bilateral supraomohyoid neck dissection .


4. resection of floor of mouth tumor .


g-tube was to gravity , foley to gravity , left radial a-line .


tomato ( causing anaphylaxis ) and tetanus shot .


he had three westwood-pocasset drains - two in the neck and one in his right arm .


polypectomy in 2011 , tooth extraction ( all ) in 1980 , and hernia in 1977 .


in addition , the patient was prepared for an attempted percutaneous endoscopic gastrostomy tube .


urine output of 900 cc .


he was weaned from ventilation on postoperative day one to pressure support ventilation and then to spontaneous breathing on postoperative day two .

ventilation
pressure support ventilation


postoperative laboratories revealed sodium was 134 , potassium was 4.1 , chloride was 102 , bicarbonate was 28 , blood urea nitrogen was 18 , creatinine was 0.8 , and glucose was 148 .

sodium
chloride
potassium
postoperative laboratories
creatinine
bicarbonate
blood urea nitrogen
glucose


triamterene/hydrochlorothiazide 37.5/25 mg one tablet by mouth once daily and lorazepam 1 mg three times daily as needed ( for anxiety ) .


tube feedings were started 48 hours after the procedure .


in addition , he received metoprolol q.4.h. , a regular insulin sliding scale , and adequate gastrointestinal prophylaxis with protonix .

a regular insulin sliding scale
protonix
metoprolol


nothing by mouth initially with morphine as needed for pain and ativan around the clock for delirium tremens prophylaxis .

delirium tremens prophylaxis
morphine
ativan


his westwood-pocasset output for postoperative day one on the left was 60 , right neck 93 , in the arm 20 .


2. diagnostic laryngoscopy and biopsy .


1. tracheostomy .


he underwent flap checks every 15 minutes initially with a dextran infusion .


complete blood count revealed white count was 5.4 , hematocrit was 31.3 , and platelets were 160 .

hematocrit
platelets
complete blood count
white count


his tracheostomy was changed to a 6 cuffless shiley on 2016-11-26 and sutures in place with a 3-0 silk .

his tracheostomy
sutures
a 3-0 silk
a 6 cuffless shiley


the patient tolerated this procedure well .


his tube feedings were advanced .


alt was 14 , ast was 31 , alkaline phosphatase was 42 , total bilirubin was 0.9 , albumin was 2.2 .

ast
alkaline phosphatase
alt
total bilirubin
albumin


the westwood-pocasset in his right arm was removed on 2016-11-25 .


the cuff on his tracheostomy tube was put down on 11-23 , postoperative day two which he tolerated well with minimal secretions and a strong adequate cough .


lopressor 5 intravenously q.4.h.


tracheostomy tube in good position .


no pneumothorax .


magnesium was 2.2 .


a chest x-ray postoperatively showed clear lung fields .


calcium was 7.6 .


he continued with pulmonary toilet and q.2h. flap checks .


cmed csru and plastic surgery flap checks , tracheostomy care , and westwood-pocasset management.

westwood-pocasset management.
tracheostomy care


medications per gastrostomy tube on postoperative day one .


includes hypertension and chronic obstructive pulmonary disease .

chronic obstructive pulmonary disease
hypertension


flap checks carried out q.2h. initially in the surgical intensive care unit showing positive biphasic doppler signals .


nebulizers as needed , weaning from ventilation .


he underwent a joint procedure by otolaryngology and plastic surgery .


foley catheter for strict monitoring of ins and outs .


he was admitted on 2016-11-21 following his surgery .


he presented on 2016-11-21 for resection .


pathology was reviewed revealing invasive squamous cell carcinoma .


unasyn for antibiotic coverage .


mr. jackson is a 63-year-old male with squamous cell carcinoma of the floor of mouth ( stage t2 n0 ) that was biopsied by his dentist .


hematocrit stable .


hearing was diminished for conversational speech .


there was no evidence of developing hydrocephalus , which was a concern due to the surrounding edema , and possible suppression of the fourth ventricle .

the surrounding edema
developing hydrocephalus
suppression of the fourth ventricle


power was mildly diminished in the finger extensors and hand intrinsics on the left , otherwise , power was full throughout .


light touch was subjectively abnormal on both sides of the face .


speech was fluent but slow , and there was long response latencies before she would initiate speech .


neurologically , she was awoken from sleep by voice , cooperative , but mildly drowsy .


she developed an ear ache , for which she saw her primary care physician , evelyn was prescribed cortisone drops .


gait was wide based , very unsteady , veering to the left and to the right .


she became more alert during the remainder of the exam .


there was decreased excursion of the right mouth and flattening of the right nasolabial fold ( mild ) .


she has had several prior bleeding events and presented with a subacute bleed in the mid to lower pons .


mrs. wisniewski is a 45 - year-old woman with a strong family history of cavernous angiomas .


there was a mild left pronator drift .


cardiovascular exam revealed a regular rate and rhythm with no murmurs , rubs or gallops .


she had sustained gaze holding nystagmus in both horizontal directions .


1. gabapentin 100 mg po t.i.d. for paresthesias .


there was no rotary component .


1. familial cavernous hemangiomas , status post a subacute pontine hemorrhage .

familial cavernous hemangiomas
a subacute pontine hemorrhage


she has had at least two bleeding episodes in the past , mostly described as being accompanied by generalized weakness .

generalized weakness
at least two bleeding episodes


she had a mildly widened right palpable fissure .


abdomen soft , nontender and distended .


she retropulsed and would have pitched backwards without the assistance of the examiner .


her hearing got progressively worse and the sound of static increased .


3. zantac 150 mg po b.i.d.


extremities showed no edema .


she otherwise had normal spontaneous movements and facial expression and did not appear to be abulic .


2. colace 100 mg po b.i.d.


she was never on an anticonvulsant due to her former beliefs as n. derk scientist .


2. severe gait ataxia .


she was seen again by primary care physician , roderick since she had complaints of dizziness , as well as a new complaint of decreased hearing and the sensation of static in her ears , meniere 's disease was considered .

decreased hearing
static in her ears
dizziness
meniere 's disease


4. prednisone taper completed .


she was very fatigued .


her physical examination remained relatively unchanged , with resolution of the subtle left hand weakness and right facial weakness .

right facial weakness
the subtle left hand weakness


therefore , it was recommended that she have aggressive physical therapy at an acute rehabilitation center .


we will arrange to have a copy of the mri scans sent to him .


there was relatively central in location , with only a slight right-sided predominance .


mra of the brain was unremarkable .


her gait remained severely ataxic , likely secondary to sensory deafferentation , as well as involvement of crossing pontine cerebellar fibers .

severely ataxic
sensory deafferentation
crossing pontine cerebellar fibers


there was no areas of restricted diffusion to indicate infarction .

areas of restricted diffusion
infarction


follow-up ct was obtained the second day of admission .


there was a large focus of subacute blood products in the mid to low pons suggesting recent hemorrhage into a cavernous angioma .


white blood cell count 7.8 with 86% polymorphonuclear cells , 11.1 lymphocytes , hemoglobin 14.3 , hematocrit 40.5 , mcv 88 , inr 1.0 , ptt 24.7 , pt 12.3 , platelet count 295,000 , glucose 81 , bun 15 , creatinine 0.8 , sodium 142 , potassium 4.2 , chloride 104 , co2 26 , calcium 9.3 , phosphate 4.8 , magnesium 2.3 .

pt
co2
potassium
chloride
hematocrit
calcium
phosphate
hemoglobin
platelet count
polymorphonuclear cells
inr
lymphocytes
mcv
creatinine
ptt
white blood cell count
glucose
bun
magnesium
sodium


notable for multiple cavernous hemangiomas .


finger tapping and rapid alternating movements were slow on the left and she had trouble isolating individual finger movements .

rapid alternating movements
finger tapping


these were seen best in gradient echocardiogram images .


mri of the brain revealed multiple foci susceptibility artifact within the brain .


this was mostly described as feeling unsteady on her feet .


there was no communication >.......< in the visualized vessels and the angiomas .


she made mistakes with position sense , roughly at chance level with both great toes and the left first finger , position sense in the right limb seems preserved .


this unsteady gait progressed , and then she subsequently started to develop a pins and needle feeling in the face , hands and feet bilaterally .


a few days later she complained of dizziness .


there was no dysarthria .


she was given an oral prednisone taper .


she had bilateral upgoing toes .


at an outside hospital , head ct revealed a 1.5 cm diameter hyperdense mass in the pons , slightly off center to the right .


there was no evidence of any special neglect .


in general , she was a thin well-appearing woman in no acute distress .


she has had at least two generalized seizures in the past , but she has not had one since she was 26 years old .


sclera were anicteric .


respiratory rate 14 .


mrs. wisniewski is a 45-year-old woman with multiple familial cavernous hemangiomas .


pulse 60 .


blood pressure 120/80 .


temperature 99.2 .


strong maternal history of hemangiomas .


there was some mild surrounding edema .


prednisone taper as above .


there was no significant change in size of the subacute pontine hemorrhage .

the subacute pontine hemorrhage
significant change in size


reflexes were brisk in the legs with 4-5 beats of clonus at the ankles bilaterally .


there are also tiny foci artifact within the cerebellum and base of the pons .


there was a larger area of susceptibility artifact in the left temporal lobe , right frontal lobe , and the splenius of the corpus collasum .


there was mild finger-to-nose dysmetria on the left .


there was mild enhancement of the pontine hemorrhagic mass but none elsewhere .


he was initially admitted to cmed for resection and repair of this left facial lesion .


he tolerated the procedure well with no complications except postoperatively , his voice was hoarse .


minimal bleeding .


head , eyes , ears , nose and throat , polypoid lesion just inferior to the left zygoma , elevated superiorly , with visible bone .


he is being discharged to rehabilitation to follow up for xrt given the fact that his pathology revealed squamous cell cancer extending deep to the margin as well as positive level ii nodes .

squamous cell cancer
positive level ii nodes


on examination , he is afebrile .


dr. navarrete has been e-mailed and his secretary contacted for as soon as possible appointment for xrt follow up .


4. aeroseb .


foley was also discontinued .


urology also followed him and kept him on antibiotics until postoperative day #7 at which point antibiotics were discontinued .


this revealed some supraglottic edema which revealed with time , without further intervention .


on scoping him he had significant supraglottic edema .


he was followed by plastic surgery for his split thickness skin graft and his bolster was discontinued on postoperative day #5 with good take up of his skin graft .

his bolster
his split thickness skin graft
his skin graft


he then went to the operating room on 2016-03-14 where he had resection of the left face squamous cell cancer by dr. langhorne and split thickness and full thickness skin grafting of the defects on 2016-03-14 .

the left face squamous cell cancer
the defects


he was kept in the unit for observation of his airway and b.i.d. laryngoscopy .


he went to the operating room on 2016-03-10 with urology for hematuria where he had a cystoscopy transurethral resection of prostate placement .


elderly man , somewhat cachectic .


his past medical history is significant for prostate cancer , benign prostatic hypertrophy , hypothyroidism , status post radiation for non hodgkin 's lymphoma , chronic painless hematuria , degenerative joint disease and history of a murmur .

benign prostatic hypertrophy
prostate cancer
degenerative joint disease
chronic painless hematuria
a murmur
non hodgkin 's lymphoma
hypothyroidism


nontender , nondistended .


clear to auscultation .


3. proscar .


vital signs , stable .


5. ancef .


last colonoscopy , five years ago .


no exudate .


1. levothyroxine .


2. lasix .


dementia .


this is an 85 year old man initially admitted to the plastic surgery service for evaluation of a left facial mass .


he also had consults from urology for his hematuria as well as medicine preoperatively and cmed ccu .


no known drug allergies .


postop course c/b right upper extremity dvt and postop afib .


over the next several days the patient was maintained on argatrobanwhile coumadin therapy was initiated .


? sleep apnea


pt - 15.0 * ptt - 107.1 * inr ( pt )- 1.3 *


s/p 2 surgs. for spermatocele


in er c/o dyspnea and was noted to have mental status changes .


calcium - 8.8 phosphate - 3.9 magnesium - 2.4


cv : rrr s1-s2 , no murmur .


keflex / heparin agents


htn


cv:rrr s1-s2 , no mrg


post-op afib


glucose - 193 * urea n - 23 * creat - 1.2 sodium - 138 potassium - 4.6 chloride - 101 total co2 - 21 * anion gap - 21 *

creat
glucose
anion gap
total co2
urea n
potassium
sodium
chloride


abdm : soft nt / nd / nabs


ext : warm well perfused no cce


abdm : soft , nt/nd/nabs


then referred to er for tx


wbc - 13.3 *# rbc - 3.45 * hgb - 10.6 * hct - 30.5 * mcv - 88 mch - 30.6 mchc - 34.7 rdw - 12.7


seasonal allergies


discharge pe


renal calculi


ext : + distal pulses , no edema


amiodarone 200 '


vs : t 99 hr 68 bp 113/72 rr 18 sat 98% ra


vs : hr 103 bp 162/69 rr 14 sat 92% ra


4. amoxicillin-pot clavulanate 875-125 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ) for 10 days .


non-contributory for premature cad ; father had mi in his 70 's


lopressor 50 "


blood wbc - 12.9 * rbc - 3.37 * hgb - 10.4 * hct - 29.4 * mcv - 87 mch - 30.8 mchc - 35.3 * rdw - 13.3 plt ct - 345

hgb
rbc
blood wbc
mch
hct
mcv
mchc
rdw
plt ct


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


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


chief complaint : pt sent to er after routine f/u for ue dvt with vascular surgery .


blood pt - 39.1 * inr ( pt )- 4.4 *


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


during er evaluation pt was noted to have some degree of dyspnea as well as mental status changes , including loss of short term memory and brief unresponsive period after one dose of iv benadry and steroids prior to ct scan .

mental status changes
loss of short term memory
brief unresponsive period
dyspnea


the pt was begun on heparin gtt and was noted to have platelet drop > 50% after infusion began , hepain was d/c 'd.


6. warfarin 2 mg tablet sig : 1.5 tablets po as directed : 3 mg 1943-05-29 and 6/1 then as directed by dr mace .


argatroban was started abd a hit panel was sent , hit panel was positive .


5. amiodarone 200 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


discharge diagnosis : s/p avr 05-14 ( tissue ) readmitted 05-24 w/ pulmonary embolism , rue dvt , hit positive


asa 81 '


neurology was consulted and the pt also had mri which was negative .


pmh : htn , renal calculi , sleep apnea ,


follow-up inr to be drawn 06-01 , by dr lewis @ 597-4427


atorvastatin 10 '


take all medications as prescribed .


discharge instructions : keep wounds clean and dry .


blood heparin dependent antibodies - positive


avr ( tissue ) 05-14


he was to have f/u inr check with dr lewis on 05-31 .


admission pe


pt admitted 05-24 from er after positive rue dvt finding in vascular lab .


the ct was negative for cva but positive for pulmonary embolism .


neuro : mae , follows commands , slightly confused


heent : perrl/eomi , no jvd


on hd#6 the pt had a therapeudic inr ( 4.4 ) off argatroban and wad discharged home .


at that time had ue duplex which revealed rue dvt involving ij , axillary , subclav , brachial , and basilic veins .


he was transferred to csru for evaluation .


s/p avr 05-14 .


by the following mornig all mental status changes had cleared and the pt was transferred to the floors for continued care .


s/p oral surgery


s/p avr ( #27 pericardial )


lisinopril 5 '


the pt was given ceftriaxone / azithromycin / vancomycin in deanna .


1. no definite pulmonary embolism is identified .


sputum culture also returned with staph. aureus .


ceftriaxone and azithro were discontinued , and vacomycin was continued .


cxr 2013-12-24 - there are faint ill-defined opacities within the right lower lung zone and left upper lung zone could represent a multifocal pneumonic process .

faint ill-defined opacities
a multifocal pneumonic process


neuts - 78.0 * lymphs - 17.0 * monos - 4.6 eos - 0.3 basos - 0.1


cxr 2014-01-02 - impression :


removal of tunneled cath ( previously used for tpn )


this is consistent with the remainder of the pt 's history including fever , chills , sob and an elevated wbc count .


multilobar pneumonia with interval worsening in the left lung but slight improvement in the right lower lobe .

interval worsening in the left lung
multilobar pneumonia


head ct 2014-01-09 - ordered to evaluate for changes to explain delta ms


the acute onset of chest pain was initially very concerning for a pe , however the chest ct demonstrated multifocal consolidation consistent with a bacterial pna .

multifocal consolidation
a bacterial pna
the acute onset of chest pain
a pe


these findings are consistent with chronic pancreatitis with pseudocyst formation

chronic pancreatitis
pseudocyst formation


left parietal subcortical hypodensity , likely ischemic .

ischemic
left parietal subcortical hypodensity


no definite changes since the mr of in 2011-05-15 .


54 yo f with crohn 's disease s/p ileostomy with subsequent short gut syndrome with port-o-cath for tpn presents with acute onset pleuritic chest pain with fever , chills , and sob .

sob
acute onset pleuritic chest pain
chills
short gut syndrome
crohn 's disease
fever


2. clonazepam 1 mg qam , 1 mg q3pm , 2 mg po qhs


6. nystatin 100,000 unit / g cream sig : one ( 1 ) appl topical bid ( 2 times a day ) .


7. lansoprazole 30 mg capsule , delayed release ( e.c. ) sig : one ( 1 ) capsule , delayed release ( e.c. ) po bid ( 2 times a day ) .


a second 9 mm cystic lesion is seen in the head of the pancreas .


ppx : ppi and heparin sc


8. quetiapine 100 mg tablet sig : three ( 3 ) tablet po bid ( 2 times a day ) .


v : 101.4 , 102 , 167/54 -> 159/77 , 24 -> 16 , 98% ra -> 96% ra


9. propranolol 10 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ) .


father - stephanie tumor , no dm , no cad


absomen soft , tender to palpation over ruq , but no guarding or rebound


10. neurontin 300 mg capsule sig : three ( 3 ) capsule po three times a day : take 2 tabs in the morining , 4 tabs in the afternoon , and 4 tabs in the evening .


pneumonia


1. quetiapine 300 mg qhs


please continue taking your medications as prescribed .


9. vistaril 50 mg once a day as needed for nausea .


2. peripheral patchy opacities are seen bilaterally , most consistent with multifocal pneumonia .

multifocal pneumonia
peripheral patchy opacities


10. zofran 4 mg po once a day as needed for nausea .


wbc - 14.4 *# rbc - 3.82 * hgb - 11.5 * hct - 33.5 * mcv - 88 mch - 30.2 mchc - 34.5 rdw - 14.7


2. carbidopa-levodopa 25 - 250 mg tablet sig : one ( 1 ) tablet po 5 times a day ( ) .


plt count - 128 *


3. pramipexole 0.125 mg tablet sig : one ( 1 ) tablet po tid ( 3 times a day ) .


cta 2013-12-24 - impression :


abd ct performed 09-01 showed multiple calcifications in the body and tail of the pancreas with a larger cystic lesion in the tail of the pancreas .


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


pt - 12.3 ptt - 26.1 inr ( pt )- 1.0


the patient was maintained sinemet .


she was also given morphine 2 mg x3 , 4 mg iv x2 , dolasetron 12.5 mg x2 and ativan 1 mg iv x1 .


2. hx of multiple port-o-cath clots :


1. crohn 's disease , dx 1974 s/p three bowel resections and eventual ileostomy , resulting in short gut syndrome

three bowel resections
eventual ileostomy


on admission she was taking quetiapine 300 mg qhs and clonazepam 1 mg qam , 1 mg q3pm , 2 mg po qhs .


the patient refused an lp .


a head ct was done which ruled out any acute processes .


they attributed it to polypharmacy , recent infection ( pneumonia ) and insomnia .

polypharmacy
recent infection ( pneumonia )
insomnia


2. restless leg syndrome


although the pt is on warfarin chronically , her inr was subtherapeutic .


ileostomy bag present with gas and stool .


8. prevacid 30 mg po twice a day .


( home regimen , gabapentin 800 mg po qam , 1600 mg po q3pm , 1600 mg po qhs .


3. ? parkinsons vs. eps side effects from risperdal


initially coumadin was increased , however given concern for infected line , general surgery was consulted who removed the line in the icu .


pt initially with mild ari , this was thought to be due to dehydration , after initial volume repletion her renal function improved to her baseline .


as the cxr was without any evidence of pna , or ptx , the pt subsequently received a cta to evaluate for pe which revealed multifocal bilateral pna but no pe .


the patient had completed her antibiotic course while in house .


at this time , she was given vancomycin 1 g iv x1 .


they felt that her presentation was secondary to delirium and was multifactorial .


54 yo f with crohn 's s/p ileostomy and subsequent short gut syndrome with port-a-cath placement for tpn who presents with progressive right sided chest pain that comes in waves .

progressive right sided chest pain
crohn 's
short gut syndrome


8. paranoia / depression , h/o auditory hallucinations , ? mania

depression
mania
auditory hallucinations
paranoia


quetiapine was continued however clonipin was initially held when she was intubated on fentynyl / versed .

versed quetiapine clonipin intubated fentynyl


3. arf :


pt initially was hypoxic requiring nrb for o2 sat of 94% , with any attempt to wean she would desat .


6. degenerative disc disease s/p two back surgeries in 80 's


mother-crohn 's ; daugher-ibs , colitis ; mother -- breast ca ,;

mother-crohn 's
breast ca
daugher-ibs
colitis


earlier that day pt had a chest x ray which showed diffuse infiltrative process concerning for ards .


she self extubated the first day and was reintubated without any complications .


( the tunneled catheter later came back for negative for culture. )


the pt has a history of paranoia / depression .


abd : obese , multiple surgical scars .


4. chronic idiopathic pancreatitis , as demonstrated on ct in 09-01


5. arthritis s/p " pin placement " in left foot 05-01


you are to return to the hospital immediately if you should experience any chest pain , shortness of breath , fevers or any other worrisome symptom .

any other worrisome symptom
any chest pain
shortness of breath
fevers


after removal of tunneled line pt was given tube feeds while she was intubated .


it is associated with sob as well as fevers , chills .


post procedure pt remained intubated on ardsnet protocol .


haldol / compazine / phenergan / tigan / flagyl


the pt reports sharp 10/10 chest pain under the right breast which is getting progressively worse .


the patient 's narcotic and cmed ccu regimen was evaluated by psychiatry during her delirium .

cmed ccu regimen
the patient 's narcotic


given her hx of ileostomy secondary to crohn 's disease and resultant short gut syndrome , the pt requires nutritional support via tpn .


the pain is worsened with deep inspiration or movement .


chest : crackles at right base with dec. air movement .

dec. air movement
crackles at right base


9. port-a-cath placement for iv hydration in setting of short gut syndrome , complicated by clotting x 4 , requiring replacement

iv hydration
replacement
port-a-cath placement


given her fever , sx of chest pain and sob as well as an elevated wbc count , she was initially thought to have a pna .

her fever
sx of chest pain
sob
an elevated wbc count
a pna


the pt denies abd pain , n/v or increased ostomy output .


at discharge the patient was on clonazepam 1 mg tid , seroquel 300 bid and neurontin 600 qam , 1200 qpm and 1200 qhs .


they made recommendations for adjustments to her anti-psychotic medications .


she was unable to sleep at night , often pacing the halls .


she was therefore given ceftriaxone 1 g iv x1 and azithromycin 500 mg po x1 in the deanna .


she was weaned off the oxygen and for the remainder of her course her o2sats were stable on room air .


social history: lives w/ her husband in john area ; smokes 05-04 cig /d ( 30 pack year history ); no alcohol or recreational drug use , has had addiction to benzodiazepines and opioids in the past


the patient remained afebrile when she transferred to the medicine service .


in addition to her usual neuropathy pain , the pt initially appeared to have significant pain from the multi-focal pna as well .

her usual neuropathy pain
significant pain
the multi-focal pna


this was held in the icu and she was given diluadid prn for pain control .


this was restarted post extubation .


after extubation her o2 requirement was down to 1l nc with sats in mid 90s .


1. amylase-lipase-protease 33,200 - 10,000 - 37,500 unit capsule , delayed release ( e.c. ) sig : four ( 4 ) cap po w/ meals and snacks ( ) .


7. saline flush


goal inr 01-31 .


tender over right chest


5. ferrous sulfate 300 mg / 5 ml liquid sig : one ( 1 ) po daily ( daily ) .


her o2 requirement improved on the vent over the next few days and she was weaned off the vent on 2013-01-01 .


the patient was transitioned to a low fat , low residue diet .


cv : rrr , s1 , s2 distant


3. ferrous sulfate 325 po daily


ext : tr edema , 2+ dp bilaterally


glucose - 208 * urea n - 21 * creat - 1.3 * sodium - 138 potassium - 4.2 chloride - 104 total co2 - 23 anion gap - 15

sodium
urea n
creat
glucose
anion gap
total co2
chloride
potassium


7. benzo and opiod addiction


4. carbidopa-levodopa 25-250 mg po 5 times per day .


pt was intubated prior to tunneled catheter removal , see below .


5. gabapentin 800 mg po qam , 1600 mg po q3pm , 1600 mg po qhs


6. heparin lock flush 10 unit / ml daily as needed .


13. warfarin 1 mg po hs .


pt 's blood cultures came back positive for staph aureus and enterococcus , both were pansensitive .


14. tpn


5. ? parkinson 's disease / akithesia :


her course later became complicated by visual and auditory hallucinations .


11. vitamin b-12 1,000 mcg / ml one injection every other week .


12. vicodin 5-500 mg 1-2 tablets po every six ( 6 ) hours prn


cxr 2014-01-09


the kindred hospital hospital course was prolonged because of her delirium .


ctropnt -< 0.01


1. chest pain / fever / chills :


chest pain


ck ( cpk )- 31


blood , urine and sputum culutres were sent .


6. pain :


she required a 1:1 sitter .


2018-10-31 06:25 am blood glucose - 91 urean - 19 creat - 0.8 na - 134 k - 4.0 cl - 98 hco3 - 26 angap - 14

angap blood glucose hco3 cl na k urean creat


coronary artery disease s/p coronary artery bypass graft x3


aspirin 81 mg qd , toprol xl 50 mg qd , mvi , flexeril 10 mg qhs , plavix 75 mg qd ( last on 10-18 )


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


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


2018-10-29 06:50 am blood pt - 11.9 inr(pt) - 1.0


2018-10-25 12:36 pm blood urean - 17 creat - 0.7 cl - 111 * hco3 - 23


11. furosemide 20 mg tablet sig : one ( 1 ) tablet po once a day for 2 weeks .


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


he did have burst of atrial fibrillation and was started on a amiodarone gtt .


6. amiodarone 200 mg tablet sig : two ( 2 ) tablet po bid ( 2 times a day ): please take 400 mg twice a day until 11-02 then decrease to 400 mg once a day for 1 week and then decrease to 200 mg once a day .


on post-op day five he appeared to have left arm phlebitis and was started on antibiotics .


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


he had no further episodes of afib while on po amiodarone .


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


the mitral valve leaflets are mildly thickened .


cath revealed severe 3 vessel disease .


he was discharged home on post-op day six with antibiotics and appropriate meds .


post-bypass : lv and rv function is unchanged .


2018-10-25 11:15 am blood wbc - 18.3 *# rbc - 3.42 * hgb - 10.9 * hct - 31.6 * mcv - 92 mch - 31.7 mchc - 34.4 rdw - 13.3 plt ct - 134 *

mcv
blood
wbc
rbc
plt ct
rdw
mch
mchc
hgb
hct


the descending thoracic aorta is mildly dilated .


7. metoprolol succinate 50 mg tablet sustained release 24 hr sig : one ( 1 ) tablet sustained release 24 hr po daily ( daily ).


he will have vna services and make the appropriate follow-up appointments .


2018-10-31 06:25 am blood wbc - 13.6 * rbc - 2.72 * hgb - 8.6 * hct - 24.6 * mcv - 91 mch - 31.7 mchc - 35.0 rdw - 14.0 plt ct - 314

mcv
blood
wbc
hct
rbc
mch
hgb
plt ct
rdw
mchc


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


chest tubes were removed on post-op day two and epicardial pacing wires on post-op day three .


mr. kammerer was a same day admit and on 10-25 was brought to the operating room where he underwent a coronary artery bypass graft x 3 .


2018-10-25 11:15 am blood pt - 13.3 * ptt - 30.0 inr(pt) - 1.2 *


pmh : carpal tunnel syndrome , hypertension , hyperlipidemia , arthritis

hypertension
carpal tunnel syndrome
arthritis
hyperlipidemia


his beta blockers were also titrated for maximal bp and hr control .

maximal bp and hr control
his beta blockers


monitor wounds for infection - redness , drainage , or increased pain

increased pain
redness
drainage
wounds
infection


left arm continue with elevation , ice , and complete all antibiotics


report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week


report any fever greater than 101


for surgical incision and left arm


no creams , lotions , powders , or ointments to incisions


67 y/o male with worsening shortness of breath. had abnormal ett and referred for cath .

abnormal ett
worsening shortness of breath.


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


4. oxycodone - acetaminophen 5-325 mg tablet sig : 1-2 tablets po q4h ( every 4 hours ) as needed for pain .


10. cephalexin 500 mg capsule sig : one ( 1 ) capsule po q6h ( every 6 hours ) for 6 days : please complete full course .


12. potassium chloride 10 meq capsule , sustained release sig : one ( 1 ) capsule , sustained release po daily ( daily ) for 2 weeks .


carpal tunnel syndrome , hypertension , hyperlipidemia , arthritis , h/o bell's palsy , hoh , s/p tonsillectomy

arthritis
hyperlipidemia
hypertension
carpal tunnel syndrome
bell's palsy
hoh


ext : warm , well-perfused - edema , - varicosities


then referred for surgical intervention .


echo 10-25 : pre-bypass : left ventricular wall thicknesses are normal .


patient recorded as having no known allergies to drugs


there are simple atheroma in the descending thoracic aorta .


he was diuresed towards his pre-op weight .


there is mild inferior wall hypokinesis .


no aortic regurgitation is seen .


right ventricular chamber size and free wall motion are normal .

free wall motion
right ventricular chamber size


later on op day he was weaned from sedation , awoke neurologically intact , and


there is no aortic valve stenosis .


shortness of breath


no pneumothorax .


cxr 10-30 : left lower lobe atelectasis has partially cleared .


trivial mitral regurgitation is seen .


mild postoperative widening of the cardiomediastinal silhouette is stable .


coronary artery bypass graft x3 ( left internal mammary -> left anterior descending , saphaneous vein graft -> obtuse marginal , saphaneous vein graft -> posterior descending artery ) 2018-10-25


father with mi in 50 's and underwent cabg .


over the next several days he continued to improve his ambulation and mobility with physical therapy .


the left ventricular cavity size is normal .


chest : ctab - w/r/r


there is akinesis / dyskinesis and thinning of the mid to distal inferior septum and the apex .


heent : eomi , perrl , nc/at


neck : supple , from , - jvd , - carotid bruits


overall left ventricular systolic function is mildly depressed .


heart : rrr - c/r/m/g


3. ranitidine hcl 150 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ).


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


vs : 65 20 160/100 5 ' 7 " 180 #


abd : soft , nt/nd +bs


general : wd/wn male in nad


for deep vein thrombosis prophylaxis she was treated with subcutaneous heparin and for gastrointestinal prophylaxis she was treated with protonix .

gastrointestinal prophylaxis
deep vein thrombosis prophylaxis
protonix
subcutaneous heparin


the patient was able to advance her diet well from liquids to solids , however , she was plagued with a persistent cough and some low grade fevers to 99.0 f .

a persistent cough
some low grade fevers


chest ct scan was negative for pulmonary embolism but positive for consolidation .


the patient had coarse rhonchi on examination .


4. she was also instructed to follow-up with dr. reid from neurology within a month at ( 382 ) 716 4151 , given her neurological deficits during this presentation .


6. atrovent multiple dose inhalers , one to two puffs q. six hours as needed .


..... done on 02-24 , notable for mid-basilar artery high-grade stenosis .


ekg is notable for sinus tachycardia at 100 beats per minute , normal axis .


2. the patient was instructed to contact dr. ralph at ( 428 ) 678-6930 , who is covering for her primary care physician , dr. erika witt , to adjust her dosages based on the inr levels .


10. seizure history on neurontin .


will also have inr checked at once weekly until target of inr of 2.0 to 3.0 is reached .


4. subcutaneous heparin taken 5000 units twice a day .


chest x-ray revealed mild pulmonary edema .


1. she was instructed to have blood drawn by the visiting nurses association the day after discharge and then a few days after discharge the same week to have inr .


5. albuterol multiple dose inhalers , one to two puffs q. six hours as needed .


3. neurontin 300 mg taken three times a day .


2. aspirin / dipyridamole 25/200 mg capsules taken two times a day .


9. depression .


she was started on levofloxacin but the patient became hypotensive at that point with blood pressure of 70/45 and received a normal saline bolus to boost her blood pressure to 99/60 ; however the patient was admitted to the medical intensive care unit for overnight observation because of her somnolence and hypotension .

blood pressure
her blood pressure
overnight observation


she awoke with nausea on the day of admission and pleuritic chest pain .


1. levofloxacin 250 mg q. day for ten days .


penicillin for which she reports a rash and dyspepsia when taking uncoated aspirin .


10. protonix 40 mg q. day .


11. zanaflex 2 mg twice a day .


8. lisinopril 2.5 mg once a day .


9. trazodone 25 mg q. h.s. p.r.n.


she has a questionable sensitivity to iodine .


physical therapy felt that the patient was cleared for transfer home with services .


7. citalopram 10 mg q. day .


2. aggrenox .


11. left cmed cataract surgery in 2009-10-05 .


12. chronic muscle spasms .


she was also evaluated by physical therapy and speech and swallow because of some report of dysphagia .


speech and swallow evaluated the patient at bedside and recommended advancing to regular diet with regular consistency and saw no evidence of any dysphagia .


she presented with three days of general malaise , nausea , vomiting , shortness of breath , cough productive of white sputum .

cough
white sputum
shortness of breath
vomiting
nausea
general malaise


4. neurontin 300 mg three times a day .


5. celexa 10 mg daily .


7. chronic diarrhea with multiple admissions for dehydration with most recent one on 2011-02-26 .


the patient was discharged on the 2011-03-15 on the following medications .


3. zanaflex .


8. venous stasis .


occupational therapy was also in agreement with the patient 's disposition home with services .


there was some question regarding restarting of the patient 's coumadin given her positive lupus anti-coagulant status as well as the presence of her basilar artery stenosis .


2. basilar stenosis .


white blood cell count were 11.8 , hematocrit 31.5 , platelets 151 .

hematocrit
platelets
white blood cell count


3. prior transient ischemic attacks .


abdomen is soft and obese , nontender .


4. right medial malleolus repair in 2004-08-05 .


chem-7 was a sodium of 140 , potassium of 3.0 , chloride 108 , bicarbonate 24 , bun 22 , creatinine 1.0 and glucose 117 .

potassium
chloride
a sodium
glucose
bun
bicarbonate
creatinine
chem-7


for her depression , continued on citalopram 10 mg daily .


for her paraplegia and associated muscle spasticity she was continued on her zanaflex .


the patient has some difficulty talking and grasping right hand .


1. positive lupus anti-coagulant .


this is an 83 year old woman with a history of hypertension who presents with slurred speech when dehydrated .


due to her chronic diarrhea she was repleted with intravenous fluids .


6. hypertension .


5. paraplegia secondary to htlv from a trip to the bahamas five to six years ago .


she has paraplegia secondary to htlv exposure while on vacation in the bahamas six years ago .


she came to the emergency department on the 2011-03-10 , with temperature of 99.0 f .; blood pressure of 97/50 ; heart rate 100 ; respirations 27 ; o2 saturation 84% on room air and 94% on two liters .

temperature
heart rate
blood pressure
o2 saturation
respirations


the patient also had a head ct scan in the emergency department before coming to the unit which reported no recent bleed and no change from a prior ct scan done on 2011-03-04 .


after transfer to the floor , the patient was continued on levofloxacin for a ten to 14 day course for presumptive pneumonia .


on admission examination she was a well developed , well nourished female in no apparent distress .


cardiovascular examination is notable for a regular rate and rhythm ; no murmurs , rubs or gallops .


her lungs revealed coarse bilateral rhonchi from base to midline .


extremities notable for two plus lower extremity edema and the ankles were noted to be in pressure stockings .


1. enteric-coated aspirin .


12. tylenol 325 mg , one to two tablets q. four to six hours p.r.n.


13. the patient was also discharged with the restarting of warfarin 2 mg daily .


this is a 47 - year-old male with a past medical history of type 2 diabetes , high cholesterol , hypertension , and coronary artery disease , status post percutaneous transluminal coronary angioplasty times two , who presented with acute coronary syndrome refractory to medical treatment and tnk , now status post angio-jet percutaneous transluminal coronary angioplasty and stent of proximal left anterior descending artery and percutaneous transluminal coronary angioplasty of first diagonal with intra-aortic balloon pump placement .

coronary artery disease
acute coronary syndrome
type 2 diabetes
hypertension
high cholesterol


in addition , he had slight shortness of breath but denies headache , change in vision , dizziness , nausea , vomiting , abdominal pain , change in bowel or urinary habits , or fevers , chills , and sweats .

headache
slight shortness of breath
nausea
change in vision
change in bowel or urinary habits
vomiting
sweats
chills
fevers
abdominal pain
dizziness


1. coronary artery disease ; the patient is status post percutaneous transluminal coronary angioplasty times three in 2009 at clinton hospital ; the patient is status post percutaneous transluminal coronary angioplasty times two in 2005 at waltham/weston hospital .


zestril 10 mg q.d. and atenolol 25 mg q.d. at discharge .


2. type 2 diabetes .


angio-jet percutaneous transluminal coronary angioplasty and stenting was performed on proximal left anterior descending artery and the percutaneous transluminal coronary angioplasty was performed on first diagonal with good results .


primary care physician was to check inr and titrate zestril up and atenolol as tolerated .


anterior apex akinesis , inferior apex akinesis , and apex akinesis .

apex akinesis
inferior apex akinesis
anterior apex akinesis


3. hypercholesterolemia .


abdomen had decreased bowel sounds , soft , nontender , and nondistended .

nondistended
nontender
decreased bowel sounds


chem-7 revealed sodium of 136 , potassium 4.7 , chloride 103 , bicarbonate 22 , bun 16 , creatinine 0.8 , glucose 284 .

potassium creatinine bun chem-7 chloride glucose sodium bicarbonate


the patient 's father died of a myocardial infarction at age 40 , and a brother who died of a myocardial infarction at age 40 .

a myocardial infarction
a myocardial infarction


no s3 or s4 .


4. hypertension .


in the emergency department he received aspirin , nitroglycerin drip , heparin drip , dilaudid , and tnk with decreased in his pain but without resolution of symptoms .

tnk
nitroglycerin drip
heparin drip
dilaudid
aspirin


neurologic examination revealed alert and oriented times three .


laboratories on admission revealed white count 7.8 , hematocrit was 41.7 , platelets of 252 , mcv 89 , rdw 12.7 .

white count
hematocrit
laboratories
rdw
platelets
mcv


the patient is a 47 - year-old male with a past medical history of coronary artery disease , status post 2-vessel percutaneous transluminal coronary angioplasty in 2005 , 3-vessel percutaneous transluminal coronary angioplasty in 2009 , hypertension , new onset type 2 diabetes , and hypercholesterolemia who presents with the sudden onset of substernal chest pain status post exercise .

coronary artery disease
substernal chest pain
hypertension
hypercholesterolemia
new onset type 2 diabetes


the patient was continued on lipitor and aspirin , and plavix was added and will be continued for 30 days post catheterization .


the right groin revealed intra-aortic balloon pump site and pulmonary artery catheterization site were clean , dry and intact without tenderness .

intra-aortic balloon pump
pulmonary artery catheterization


electrocardiogram at that time showed st elevations and j point elevations in v2 through v4 .

st elevations
j point elevations in v2 through v4


an intra-aortic balloon pump was placed at this time as well .


9. coumadin 5 mg p.o. q.d.


pt 14.2 , ptt 108.5 , inr 1.3 .


the pain became worse over the next few minutes to 07-12 and increased to 10-12 while he was in the ambulance .


the patient was continued on heparin throughout his hospital course and transitioned to coumadin on hospital day four .


5. atenolol 25 mg p.o. q.d.


pulmonary artery pressure was 29/15 with a mean of 22 .


electrocardiogram post catheterization showed continued st elevations and j point elevations in v2 through v3 .

j point elevations in v2 through v3
continued st elevations


extremities had no edema .


the patient presented to bournewood hospital on the morning of admission with a chief complaint of substernal burning without radiation which developed while doing exercise .


the patient was transferred to sturdy memorial where he underwent catheterization .


cardiac output was 7 ( that was on 6 of dopamine ) .


the was trace mitral regurgitation and trace tricuspid regurgitation .

trace mitral regurgitation
trace tricuspid regurgitation


8. glucophage 500 mg p.o. q.d.


6. zestril 10 mg p.o. q.d.


catheterization results showed 100% occlusion of the proximal left anterior descending artery and 50% stenosis of first diagonal .


no hepatosplenomegaly .


the patient was lying flat in no apparent distress .


intra-aortic balloon pump augmented systole was 109 , augmented diastole was 111 .


post catheterization echocardiogram showed an ejection fraction of 30% , moderate systolic dysfunction , basal anterior hypokinesis , mid anterior akinesis , basal anteroseptal hypokinesis , mid anteroseptal akinesis .

moderate systolic dysfunction
basal anterior hypokinesis
mid anterior akinesis
basal anteroseptal hypokinesis
mid anteroseptal akinesis

post catheterization echocardiogram
an ejection fraction


no murmurs , rubs or gallops .


his nitroglycerin patch did not help , and he only had slight relief with sublingual nitroglycerin times three .

his nitroglycerin patch
sublingual nitroglycerin


cardiovascular revealed jugular venous distention not appreciated .


lungs were clear to auscultation bilaterally , anteriorly and laterally .


1. lipitor 10 mg p.o. q.d.


the patient was continued on lopressor and captopril throughout his hospital course , and changed to


no lymphadenopathy .


3. plavix 75 mg p.o. q.d. times 30 days .


temperature maximum 98.7 , temperature current 98.3 , pulse ranged from 82 to 92 , blood pressure 104 to 124/67 to 74 with a mean of 86 to 99 , respiratory rate of 11 to 16 , oxygen saturation 94% to 98% on 2 liters .

pulse
temperature current
temperature maximum
oxygen saturation
respiratory rate
blood pressure


4. prevacid 30 mg p.o. q.d.


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


dopamine was discontinued on day one .


the intra-aortic balloon pump was discontinued on day two .


7. glyset 25 mg p.o. q.d.


diltiazem 180 mg p.o. q.d. , lipitor 10 mg p.o. q.d. , glyset 25 mg p.o. q.d. , prevacid 30 mg p.o. q.d. , metoprolol 50 mg p.o. b.i.d. , glucophage 500 mg p.o. q.d.

glucophage prevacid metoprolol glyset diltiazem lipitor


allergies included penicillin and iodine .


the patient was discharged to the medical floor on hospital day three and discharged from the hospital once his inr was within the 2 to 2.5 range .


carotids had normal upstroke and normal volume with bilateral bruits .


dorsalis pedis pulses were 2+ bilaterally .


creatine kinase at 11 a.m. was 83 , at 5 p.m. was 3021 .


arterial blood gas at 11 a.m. was 7.33/46/115 .


creatine kinases trended from 11:15 on the day of admission from 83 to 3021 at 5 p.m. to 3450 at 11 p.m. , to 1734 at 5:30 a.m. on 11-07 , to 1277 at 11:30 a.m. on 11-07 , to 83 at 9:30 a.m. on 11-11 .


the cardiac monitor showed occasional irregularities in a paced rhythm .


2017-09-03 pt - 13.8 * ptt - 33.1 inr ( pt )- 1.2 *


epoetin 4000 units mwf


spironolactone 25 mg po daily


pt. was initially admitted to ccu on 2017-09-03 , transferred to pendleton on 2017-09-05 , triggered on 2017-09-10 for hypotension with bp 67/38 and transferred back to ccu on 2017-09-10 .


tiotropium bromide


the patient was therefore intubated for ventilation , and continued to be diuresed .


fluticasone / salmeterol


all sedating medications were held and serial abgs were trended to follow the resolution of the metabolic alkalosis .


his co2 improved and he was extubated after a few days .


asa 81 mg po daily


simvastatin 40 mg po qhs


2017-09-03 glucose - 206 * urea n - 28 * creat - 1.8 * sodium - 135 potassium - 4.1 chloride - 85 * total co2 - 42 * anion gap - 12

anion gap
urea n
creat
sodium
potassium
chloride
total co2
glucose


pantoprazole 40 mg po daily


s1 , s2 with grade ii/vi sem . +s3 .


subq heparin


calcium acetate 667 mg po tid


soft , nt/nd with normoactive bs .


amiodarone 200 mg po daily


pump


2. levothyroxine 100 mcg tablet sig : one ( 1 ) tablet po daily ( daily ) .


3. duloxetine 20 mg capsule , delayed release( e.c. ) sig : one ( 1 ) capsule , delayed release ( e.c. ) po qhs ( once a day ( at bedtime ) ) .


he had 4 surgeries ( 3 cardiac surgeries ) earlier in the summer , so it is likely that he required copious ivf hydration surrounding these procedures which may have been the cause of his massive fluid overload .

copious ivf hydration
these procedures
3 cardiac surgeries
4 surgeries


this acutely worsened on 2017-09-18 , when the patient was found to have mental status changes and an abg revealed a co2 of over 100 , likley due to a depressed respiratory drive secondary to sedatives given for agitation on top of a preexisting alkalosis .

agitation
mental status changes
a preexisting alkalosis
a depressed respiratory drive


1. docusate sodium 100 mg capsule sig : one ( 1 ) capsule po tid ( 3 times a day ) as needed for constipation .


mvi


tylenol prn


likely due to chf exacerbation , with diuresis of over 36 l during his admission .


5. fluticasone - salmeterol 100-50 mcg / dose disk with device sig : one ( 1 ) disk with device inhalation bid ( 2 times a day ) .


he remained fluid overloaded and a swan catheter was placed .


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


he is not ambulatory and is very deconditioned secondary to several complications within the past two months related to an aicd pocket infection .

several complications
an aicd pocket infection
very deconditioned


3# metabolic alkalosis / hypochloremia :


4. lactulose 10 g / 15 ml syrup sig : thirty ( 30 ) ml po bid ( 2 times a day ) .


he was then transitioned to oral lasix for maintainence .


the patient was started on levofloxacin at newton-wellesley hospital for a question of uti based on u/a positive for wbc .


9. oxycodone - acetaminophen 5-325 mg tablet sig : 1-2 tablets po q4-6h ( every 4 to 6 hours ) as needed for pain .


97.6 95/48 71 98% 4l nc


the patient had an echo on 2017-09-04 with the results above in detail .


slight confustion with place but oriented with some re-direction .


7. amiodarone 200 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


- hyperlipidemia


8. calcium acetate 667 mg capsule sig : one ( 1 ) capsule po tid w/meals ( 3 times a day with meals ) .


- s/p bovine avr 1999


13. simvastatin 40 mg tablet sig : one ( 1 ) tablet po qhs ( once a day ( at bedtime ) ) .


- copd


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


he also had a high co and low svr suggestive of sepsis , but he never had an elevated wbc and was afebrile during his entire hospital admission with negative blood , urine , wound , and pleural fluid cultures .

a high co
sepsis
low svr
an elevated wbc
afebrile


- t2dm c/b neuropathy and nephropathy


14. pantoprazole 40 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po daily ( daily ) .


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


sister with diabetes .


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


- lumbar sympathectomy


- chronic lbp


a swan was placed for a more accurate picture of his volume status and he was volume overloaded by swan numbers with an elevated pad and elevated cvp without an obtainable wedge pressure .

volume overloaded
elevated cvp
an elevated pad

a swan
swan numbers
an obtainable wedge pressure


the lasix drip was eventually changed to iv lasix boluses , with a net diuresis of over 36 liters for the hospital stay .

a net diuresis
the lasix drip
iv lasix boluses


19. spironolactone 25 mg tablet sig : two ( 2 ) tablet po daily ( daily ) .


inr 3.5 , pt 32.5 , ptt 41


20. albuterol 90 mcg/actuation aerosol sig : 4-6 puffs inhalation q6h ( every 6 hours ) .


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


15. lidocaine 5 %( 700 mg / patch ) adhesive patch , medicated sig : two ( 2 ) adhesive patch , medicated topical daily ( daily ) .


16. furosemide 40 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ) .


2017-09-03 ck ( cpk )- 38


2017-09-03 ck - mb - not done ctropnt - 0.22 *


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


18. epoetin alfa 4,000 unit/ml solution sig : one ( 1 ) injection qmowefr ( monday - wednesday - friday ) .


24. warfarin 1 mg tablet sig : one ( 1 ) tablet po at bedtime : please monitor inr with goal 02-24 .


congestive heart failure exacerbation


- cva


- gerd


coronary artery disease


- cad s/p lad ptca 33 years ago


22. finasteride 5 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


2017-09-03 ck ( cpk )- 16 *


2017-09-03 ck - mb - not done probnp - 2656 *


23. gabapentin 300 mg capsule sig : one ( 1 ) capsule po bid ( 2 times a day ) .


his mental status did clear somewhat with the addition of standing lactulose ; he was discharged on this medication .


4. echo 2017-09-14


an eeg showed mild encephalopathy , but no other findings .


the patient was started on glargine for tighter glycemic control and was covered with an insulin sliding scale .


the patient was initially admitted for likely chf exacerbation .


the left atrium is mildly dilated .


the patient was continued on his outpatient dose of levothyroxine .


gram stain and cultures were negative , cytology was negative .


9# hypothyroidism :


all cultures , including bcx , ucx , pleural fluid culture , and wound culture have been negative .

all cultures
ucx
bcx
wound culture
pleural fluid culture


however , he still appeared volume overloaded with minimal improvement in his oxygen requirement .

volume overloaded
his oxygen requirement


70 y/o male with h/o cad , t2dm , hyperlipidemia , and copd who presented to the juan on 2017-09-03 with worsening sob x 5 days from morton hospital & medical center .

copd
hyperlipidemia
t2dm
cad
worsening sob


gradually , the dopamine gtt was weaned .


compared with the prior study ( images reviewed ) of 2017-09-04 , there is probably no significant change .


he diuresed well on the dopamine gtt and his bp was supported .


10# ? uti :


the right pleural effusion slowly re-accumulated after tap but resolved after continued diuresis .


he was transferred back to the ccu and started on a dopamine gtt .


he was given percocet for back pain , lasix 80 mg iv , and combivent neb .


after several days , he became hypotensive and triggered for bps 60s/30s .


ucx during this hospitalization were negative and levofloxacin was d/c 'd .


he was given ivf without an adequate response in his pressures .


in the juan , his vs were 97.8 150/80 88 12 89-94% 3l nc .


medications , metabolic disturbances , and infection are among the most common causes .


the patient was treated with a lidocaine patch and percocet prn .


he was monitored with qid fingersticks .


11# chronic lower back pain :


stronger narcotics were avoided given somnolence and ms changes .


- ischemic colitis and ischemic liver 2017-06-22 ( post air embolism from post mediastinal exploration )

ischemic colitis
ischemic liver
air embolism


abnormal eeg due to the moderately slow posterior background and occasional bursts of generalized slowing .


repeat cxr showed improvement of the effusion and on discharge he had been breathing well on room air without complications


5# t2dm :


the patient has left chest wound and left gluteal pressure ulcer .

left chest wound
left gluteal pressure ulcer


the patient is completely pacer-dependent , being epicardially paced at 70 .


12# wound care :


for the left gluteal pressure ulcer , they recommended gentle cleansing with normal saline or commercial wound cleaner , thin layer of duoderm gel , air dry , allevyn foam adhesive over the site , and change every 2 days or prn .

gentle cleansing
normal saline
commercial wound cleaner
duoderm gel
allevyn foam adhesive


no prominent focal abnormalities were evident , and there were no epileptiform features .

epileptiform features
prominent focal abnormalities


the aortic valve leaflets are mildly thickened .


overall left ventricular systolic function cannot be reliably assessed .


there is no evidence of intraaxial or extraaxial hemorrhage , mass effect , shift of normally midline structures , or acute major or minor vascular territorial infarction .


the patient 's inr became supratherapeutic and coumadin was held .


anti-coagulation was started with warfarin 5 mg with a goal of 2-3 and a plan for cardioversion in 6 weeks .


again seen are subtle hypodensities within the periventricular white matter which is an indication of chronic microvascular ischemic changes , stable .


for the left chest wound , they recommended cleansing with commercial wound cleanser , pat dry , pack aquacel ag rope and moisten with saline , cover with dry gauze and change daily .

commercial wound cleanser
saline
pack aquacel ag rope
dry gauze


his coumadin was transitioned to 2 mg and then 1 mg .


he was quickly weaned to 3l o2 via nc , o2 sats 100% .


stable microvascular ischemic changes in the periventricular white matter .


it appears that his diet was regulated at rehab but there is concern for medication non-compliance at rehab , per previous discharge summaries .


8. 2017-09-30 eeg :


on discharge , the patient was maintained on standing diuretics as well as prn nebs and inh copd meds .

standing diuretics
inh copd meds
prn nebs


he was started on finsateride on the day prior to admission .


extensive carotid artery calcifications are identified .


until then , his foley should remain in place .


no evidence of acute or chronic infarction .


levothyroxine 100 mcg po daily


duloxetine 20 mg po qhs


single ap view of the chest .


the mitral valve leaflets are mildly thickened .


mild cardiomegaly is stable .


ondansetron prn


a small right pleural effusion has decreased in size .


percocet 1 tab prn


6. 2017-09-28 chest x ray :


senna prn


colace prn


lasix 80 mg po bid


there has been almost complete resolution of pulmonary edema .


almost complete resolution of pulmonary edema .


his inr continued to flucuate .


lactulose prn


he was started on a lasix gtt the night of admission with a good response .


his inr will have to be monitored closely unitl his levels are stable .


lidocaine patch


7. 2017-09-29 ct head :


this am while talking with his daughter on the phone , he was noted to desaturate into the high 80s and he was brought to the the hospital for orthopedics juan for further evaluation .


there is no pneumothorax .


his inr goal is 02-24 .


nystatin powder


2# sob on admission :


gabapentin 300 mg po tid


patient is post median sternotomy .


alb nebs


right pic catheter tip ends in the lower svc .


the patient had another echo on 2017-09-14 with no new changes .


scattered parenchymal opacities in the left lower lobe represent superimposed infection vs atelectasis .


he was continued on aspirin , metoprolol and lipitor with no further issues .


underlying infectious consolidation in the right lower lobe not excluded .


the patient had an initial troponin bump on admission which was most likely secondary to chf exacerbation .

an initial troponin bump
chf exacerbation


1. increasing large right-sided pleural effusion and pulmonary edema .


ischemia


there is no evidence of abscess .


central venous catheter and swan ganz catheter placement

central venous catheter
swan ganz catheter placement


his dry weight is 70.4 kg .


at discharge the patient was thought to be euvolemic , satting well on room air and without peripheral edema .


a bioprosthetic aortic valve prosthesis is present .


the left ventricular inflow pattern suggests a restrictive filling abnormality , with elevated left atrial pressure .

a restrictive filling abnormality
elevated left atrial pressure


the aortic prosthesis leaflets appear to move normally .


5. ct chest 2017-09-16 :


it was unchanged in comparison to 2017-08-14 with similar ventricular function and inferior and inferolateral hypokinesis .


endotracheal intubation


etiology most likely a combination of contraction alkalosis and / or post-hypercapnia .


the transaortic gradient is normal for this prosthesis .


there is no pericardial effusion .


riss


there is mild symmetric left ventricular hypertrophy .


3. echo 2017-09-04


his underlying rhythm is atrial flutter ; it was unclear whether he had previously been cardioverted .


the patient states that he has felt " cloudy " of late which seems to relate to his worsening sob .


resting regional wall motion abnormalities include inferior and inferolateral hypokinesis .


medicine


4# pleural effusions : s/p right thoracentesis on 2017-09-06 , 1600 ml of serosanguinous fluid removed from right pleural space .


compared to pa and lateral chest of the prior day .


rhythm


the heart is markedly enlarged .


his blood sugars were in the 100s on discharge .


right-sided picc line with its tip in the distal svc .


there remains a large right and small left pleural effusion , not significantly changed .


patient remains in congestive heart failure , though it may be slightly improved compared to the prior study .


lv systolic function appears depressed .


congestive heart failure with bilateral effusions ( r > l ) , with possible underlying consolidation in the rll and to a lesser degree the rml and lll .

congestive heart failure
bilateral effusions
underlying consolidation in the rll


he is on amiodarone for post-op afib and this was continued this entire admission .


the ventricles and sulci are mildly prominent , but stable in size and appearance .


2. cxr 2017-09-04


for unclear reasons , he was placed on a nrb in the juan .


neurology was also consulted and a head ct showed old lacunar infarcts but no acute causes for a change in mental status .

a change in mental status
old lacunar infarcts


1. cxr ( pa/lateral ) 2017-09-03


the patient has a history of baseline dementia which was confounded by delerium in the face of metabolic abnormalities .

delerium
metabolic abnormalities
baseline dementia


right ventricular chamber size is normal and free wall motion may be mildly impaired .


2017-09-03 wbc - 9.1 rbc - 2.77 * hgb - 8.8 * hct - 27.2 * mcv - 99 * mch - 31.9 mchc - 32.4 rdw - 18.0 *


the patient was continued on nebs


8# ms changes :


6# hyperlipidemia :


7# copd :


the left atrium is mildly dilated .


the patient was continued on his statin .


70 y/o male with h/o cad s/p lad ptca 33 yrs ago , copd , t2dm , and aicd pocket infection who presented to the juan on 2017-09-03 with worsening sob x 5 days and feeling " cloudy ."

cad
copd
t2dm
worsening sob
aicd pocket infection


arterial line placement


2017-09-03 neuts - 79.5 * lymphs - 9.9 * monos - 4.9 eos - 5.4 * basos - 0.2


- hypothyroidism


he denies any cp , n/v/d , abdominal pain , or ha .


2017-09-03 hypochrom - 2+ anisocyt - 1+ macrocyt - 2+


2017-09-03 plt count - 124 *


shortness of breath


2+ pitting edema to knees b/l .


patient recorded as having no known allergies to drugs


crackles halfway up lung fields b/l .


jvd difficult to access 02-23 increased neck girth .


the patient was currently at hubbard regional hospital and began to develop worsening sob for the past 5 days .


right sided thoracentesis


transmitral doppler and tissue velocity imaging are consistent with grade iii/iv ( severe ) left ventricular diastolic dysfunction .

transmitral doppler
tissue velocity imaging


- aicd pocket infection c/b mssa bacteremia , pericardial effusion s/p mediastinal exploration , evacuation of pericardial effusion & hematoma ( 2017-07-24 )

pericardial effusion
hematoma
pericardial effusion
aicd pocket infection
mssa bacteremia


3. please call your pcp c. lettinga or seek medical attention in the juan if you experience worsening shortness of breath , chest pain , dizziness , passing out , or any other concerning symptom .

any other concerning symptom
chest pain
dizziness
passing out
worsening shortness of breath


these findings indicate a widespread encephalopathic condition affecting both cortical and subcortical structures .


compared with the prior study ( images reviewed ) of 2017-08-14 , ventricular function is now similar.


ef 35-40% .


the aortic root is mildly dilated .


the aortic valve leaflets are mildly thickened .


during this admission you have been treated for a chf exacerbation .


1. please take all medications as prescribed .


the ascending aorta is mildly dilated .


there is mild pulmonary artery systolic hypertension .


the patient was discharged hemodynamicallly stable , afebrile with appropriate follow up .


the tricuspid valve leaflets are mildly thickened .


there is no pericardial effusion .


hypertension


type 2 diabetes mellitus


chronic obstructive pulmonary disease


he then became dusky and cyanotic , and stopped breathing on his own .


however , they felt this event could not account for his new , severe global deficit ; this was thought to be secondary to a more pervasive process , likely anoxic encephalopathy , for which the prognosis is extremely grim .

a more pervasive process
his new , severe global deficit
anoxic encephalopathy


old twi v4-6 .


atrial fibrillation , occasional v-paced , rate 74 .


ekg in john :


anemia of chronic disease


mr. lockley is a 73 yo male with a complicated past medical history , recently discharged from st. margaret 's center for women & infants on 08-02 following a prolonged admission for stemi , respiratory failure felt secondary to pulmonary edema requiring intubation and subsequent tracheostomy 02-22 failure to wean , sepsis and c.difficile colitis treated with vancomycin and flagyl with a course of levophed .

sepsis
respiratory failure
pulmonary edema
failure to wean
c.difficile colitis
stemi

subsequent tracheostomy
vancomycin
flagyl
levophed


the left ventricular inflow pattern suggests impaired relaxation .


at osh , sputum cultures grew pseudomonas and mrsa , and he was restarted on zosyn ( 08-08 ) and vancomycin ( 08-09 ).


mild ( 1+ ) aortic regurgitation is seen .


jevity 1.2 65 ml / hour continuous with water 240 cc q 8 hours


long qt interval ( qtc 462 ms ).


st depressions v4 , 5 .


in john , bp 80/60 , hr 80 .


he was disconnected from the ventilator and all medications beyond a morphine drip were stopped , and he expired shortly thereafter .

the ventilator
a morphine drip
all medications


2017-08-15 sputum culture - preliminary { pseudomonas aeruginosa }


lansoprazole 30 mg po qam


he was transferred to st. margaret 's center for women & infants john for further management on ac , rr 15 , peep 5 , vt 500 , fi02 1.0 .


there is no aortic valve stenosis .


hyponatremia


asa 325 mg po qd


mild st elevation in v3 .


2017-08-14 cxr :


vancomycin 1 gm iv q 36 hours ( last dose at 2000 on 08-13 ) .


ac , rr 15 , peep 5 , vt 500 cc , fio2 1.0 .


abg done on fio2 100% 7.36/66/417/98% .


lasix 40 mg iv qam ( given 08-14 )


old twi v4-6 .


metoprolol 37.5 mg q 12 hours ( last dose 07/25 in am )


the ascending aorta is mildly dilated .


s/p right pneumonectomy .


patient placed on fio2 100% .


zosyn 4.5 gm iv q 8 hours ( last dose on 08-14 at 1400 ) , started 08-08 .


vitals reportedly hr 88-98 , bp 150/80 .


blunting of left cpa likely effusion .


heparin 5000 units sc tid


ipratropium / albuterol inhaler 4 puffs qid


1. non-small cell lung cancer s/p xrt and chemotherapy in french guiana , s/p right pneumonectomy in 2016-09-21 for recurrence .

s/p xrt
chemotherapy
s/p right pneumonectomy


completed course of flagyl 07-25 --> 08-10 .


new lower left lateral cw opacity , likely loculated pleural fluid .

new lower left lateral cw opacity
loculated pleural fluid


unchanged appearance of right pneumonectomy .


there is a small pericardial effusion .


resting wma include mid to distal septal akinesis , apical akinesis , inferior akinesis/hypokinesis , and mid to distal anterolateral hypokinesis / akinesis .

mid to distal septal akinesis
apical akinesis
inferior akinesis/hypokinesis
mid to distal anterolateral hypokinesis
akinesis


pseudomonal pneumonia


2017-07-19 echo :


anoxic encephalopathy


medicine


volume overload


left-to-right shunt across the interatrial septum .


continued on ivf ( received total 2300 cc ) , with improved bp to sbp 105-118 .


chronic respiratory failure


lvef 25% .


1. non-small cell lung cancer s/p xrt and chemotherapy in western sahara , s/p right pneumonectomy in 2016-09-21 for recurrence .

s/p right pneumonectomy
chemotherapy
s/p xrt


trivial mitral regurgitation is seen .


ekg without acute changes .


at vencor hospital , bp dropped to 90 , and patient was started on ns ivf , with improvement in bp .


on this head ct without contrast , the evaluation is limited .


4. hypertension


chronic left pleural effusion .


2. sick sinus syndrome status post pm/icd placement


no definite apical thrombus seen ( cannot exclude ).


+ s4 .


01-22+ ar .


wbc - 4.9 rbc - 2.92 * hgb - 8.8 * hct - 26.2 * mcv - 90 mch - 30.1 mchc - 33.5 rdw - 18.5 * neuts - 86.5 * lymphs - 7.5 * monos - 4.7 eos - 1.2 basos - 0.1 plt count - 145 * glucose - 91 urea n - 21 * creat - 0.6 sodium - 143 potassium - 4.2 chloride - 106 total co2 - 32 anion gap - 9 lactate - 1.4 k+ - 3.9

lymphs
neuts
rdw
urea n
basos
eos
monos
creat
glucose
plt count
chloride
potassium
sodium
lactate
k+
total co2
anion gap
hct
mcv
mch
mchc
wbc
rbc
hgb


ronchorous breath sounds left chest .


peg in place , site without drainage .


there are no echocardiographic signs of tamponade


1+ tr .


trivial mr .


chronic obstructive pulmonary disease


2017-08-16 ct head :


no epileptiform features were seen .


no murmur appreciated .


intubated , opens eyes , responds to painful stimulus .


new rounded low-density area measuring 2.5 cm in left basal ganglia , which partially extends to the left thalamus , probably representing subacute infarction .

subacute infarction
new rounded low-density area


he was thoroughly evaluated by neurology and underwent head ct , mri , lp , and eeg .


bp 90s-118/47-59 , hr 80-90s .


there was also evidence of subcortical dysfunction on the right side .


findings consistent with failure or fluid overload .


13. status post tracheostomy 2017-07-21 02-22 failure to wean


the end result of these discussion was that the patient 's wishes would not be consistent with this new level of functioning from which he had little hope of recovery ; the family decided to make him comfort measures only .


limited examination .


development of small loculated pleural fluid collection along the periphery of the left major fissure or so-called pseudotumor , consistent with the recent chest x-ray .


2017-08-16 echo :


opens eyes spontaneously , withdraws to painful stimulus .


overall lvef is difficult to assess due to poor echo windows although the basal lv appeas hyperdynamic without regional contraction abnormality ( suspect significant improvement compared to prior study dated 2017-07-18 ).

hyperdynamic
regional contraction abnormality

overall lvef
the basal lv
prior study
echo windows


per dr. john c. corrigan mental health center , patient remained ventilator dependent , intermittently on ps 20/5 and back on ac 15/5/500/0.35 on 08-08 .


2017-08-14 07:30 pm type - art po2 - 468 * pco2 - 44 ph - 7.50 * total co2 - 36 * base xs - 10 intubated - intubated


2017-08-17 eeg :


markedly abnormal portable eeg due to the voltage suppression over the left hemisphere and due to the bursts of generalized slowing and right hemisphere slowing .


the first abnormality raises the possibility of material ( such as subdural fluid ) interposed between the brain and recording electrodes or widespread cortical dysfunction on that side .


the generalized slowing indicates a non specific dysfunction in midline structures .


unable to assess jvp .


mr. lockley was admitted with respiratory failure , thought to be related to mucus plugging as well as a pseudomonal pneumonia .

a pseudomonal pneumonia
respiratory failure
mucus plugging


bronchiectasis


however , the issue that dominated the admission was his recent acute decline in mental status .


this work-up demonstrated a small left basal ganglia infarct , likely cardioembolic .

a small left basal ganglia infarct
cardioembolic


ekg ( at athol memorial hospital , 17:11 ) :


14. status post partial colectomy 1972


12. status post peg tube placement 2017-07-21


stool sent for c.diff and given flagyl 500 mg po x 1 dose .


2017-08-16 cta chest :


10. recent mrsa pneumonia and sepsis 2017-07-21 , treated with vancomycin


2017-08-17 stool clostridium difficile toxin assay - pending


no masses or thrombi are seen in the left ventricle ( due to poor echo windows cannot fully exclude ).


3. copd/bronchiectasis


bronchial breathing over right hemithorax .


withdraws to painful stimulus .


sclera anicteric .


pupils minimally reactive .


9. left femoral av fistula 2017-04-19


2+ edema both upper extremities , sacral edema .

sacral edema
2+ edema both upper extremities


8. depression


cool extremities .


2017-08-16 csf ; spinal fluid gram stain - neg fluid culture - neg ; fungal culture - pending ; acid fast culture - pending ; viral culture - pending

fungal culture
fluid culture
spinal fluid gram stain
viral culture
acid fast culture


limited examination .


7. bph


6. chf with ef 25% on last echo on 2017-07-19


foley in place .


protein / soy supplement 2 scoops q 12 hours


11. c. difficile colitis treated with flagyl ( completed 08-10 )


afib , occasional v-paced , rate 83 bpm .


5. cad , with known to rca .


no evidence for pulmonary embolism .


acute respiratory failure


4. hypertension


2017-08-15 blood culture ngtd


sulfonamides


chronic left pleural effusion .


abg :


lumbar puncture on 08-16


ett in correct position .


2. sss status post pm/icd placement


pm wires in good position .


however , today around 17:45 , while being moved by the nursing staff , mr. lockley bosche started coughing .


no grimacing with palpation .


2017-08-15 urine culture - final


he completed his course of vancomycin on 2017-08-10 .


bs present , hypoactive .


transfer from athol memorial hospital for acute on chronic respiratory distress .


he was discharged to athol memorial hospital for continued weaning .


13. status post tracheostomy 2017-07-21 02-22 failure to wean


14. status post partial colectomy 1972


12. status post peg tube placement 2017-07-21


a code was called , + pulse .


nt .


3. ecg changes - patient had an episode of chest pain during her hospital stay that was both right and left sided with no radiation and no associated symptoms .

associated symptoms
chest pain
ecg changes


nasal washings for influenza were negative ; culture pending .


abdomen - obese .


11. s/p l shoulder hemiarthroplasty following a left humeral fracuture in 2018-11-10- dumas was complicated by a pea arrest secondary to pe .

a left humeral fracuture
a pea arrest
pe


2. respiratory - intubated for airway protection due to change in mental status .


in the juan , the pt 's vs were singificant for a fever of 103.8 , tachycardia in the 130s-150s , and initial hypertensive in the 140s .

initial hypertensive
tachycardia
a fever


nd .


per pt 's son , she is bedbound at baseline due to her multiple le femur fractures .

bedbound
her multiple le femur fractures


cultures drawn off the hd cath are negative to date .


she was given flagyl for presumed c. diff. colitis , however this was stopped when c. diff b toxin came back negative on 2019-01-10 .


extremities - feet mildly cool .


9. hypertension


extubated 12-28 with no incident .


patient was found to have a new humerus fracture distal to the hardware on film this admission .


10. anemia of chronic disease


2+ dp pulses bilaterally .


medicine


plan to continue vancomycin for 08-19 day course to treat empiric line infection .


ac 500 / 15 / .50 / peep 5


wound care should be continued as described after discharge .


on 12-18 flagyl and cefepime were discontinued as all culture data negative to date .


question mild erythema and warmth of left le .


c diff neg : 12-28 , 12-31 , 01-01 , 01-02 .


gen - sedated and intubated .


however , a septic component to the hypotension was also considered as the pt was found to have citrobacter in her urine and c diff in her stool .

c diff in her stool
citrobacter in her urine
the hypotension
a septic component


urine cx 12-26 : > 100k vre likely colonized , 01-03 yest and vre


anicteric sclera .


chronic kidney disease - on hemodialysis type 2 diabetes hypercholestrolemia anemia of chornic disease h/o pe , s/p pea arrest 11-14

s/p pea arrest
anemia of chornic disease
type 2 diabetes
chronic kidney disease
pe
hypercholestrolemia


steroids were discontinued .


2. diabetic nephropathy resulting in esrd for which she is on hd .


echo was obtained which showed wma and ef of 35-40% .


pt was note started on asa as she does not tolerate this well , bb was also not started given sbps in the 110s .


no m,r,g .


coumadin was stopped and she received ffp for tunneled line change over a wire .

tunneled line change over a wire
ffp
coumadin


8. back pain


urine culture came back positive for vre , however , since patient improved without treatement ( ie linezolid ) initially .


unclear etiology headache over the three days prior to admission in association with fever was concerning for a cns etiology .


when pt spiked a temperature and became hypotensive she was started on linezolid was started for presumed vre infection in the urine .

vre infection in the urine
hypotensive
a temperature


on the floor the vancomycin was discontinued as the catheter tip culture was negative .


on vit c. and zinc as well to aid w/ wound healing .


id was consulted who suggested broad spectrum antibiotics if she were to spike .


coumadin was restarted at a dose of 2 mg qhs .


12. pe 2018-11-17 leading to pea arrest


if you have chest pain , shortness of breath , diahrrea or fevers please contact your pcp .

chest pain
shortness of breath
diahrrea
fevers


her left knee is slightly erythematous compared to the right but not impressive .


5. type 2 dm - patient was initially covered with an insulin drip while septic and then transitioned back to insulin sliding scale .


3. status post left femur fracture


6. esrd on hd - pt has esrd secondary to her dm and is on hd .


4. hyponatremia


she was dialysed but was slightly limited by hypotension .


she was also started on fluconazole for yeast in the urine , to be treated with fluconazole for total 7 days .


5. hypercholesterolemia


6. unsteady gait


patient 's le ulcers appear chronic and do not appear to be the source of infection .


7. cataracts


color - yellow appear - slhazy sp barajas - 1.005


the tunneled catheter line was changed over a wire and the tip was also negative .


the picc line should be discontinued promptly after the linezolid course is completed .


2018-12-26 08:28 pm urine


1. type 2 diabetes mellitus


per notes , pt denied sob , cp , and abdominal pain prior to intubation .


she normally receives hd on mon , wed , and fri .


blood - lge nitrite - neg protein - 500 glucose - tr ketone - neg bilirubin - neg urobilngn - neg ph - 7.0 leuk - neg

blood
protein
glucose
ketone
urobilngn
bilirubin
ph
leuk
lge nitrite


pt was due for hd but missed it secondary to her illness .


when this medication was discontinued , her bp came back up to the 70s-90s / 30s-50s .


sepsis -? source


in the juan , she received vancomycin , levofloxacin , flagyl , and cefepime ( 2 gm ).


rbc - 225 * wbc - 8 * bacteria - none yeast - none epi - < 1


ck ( cpk )- 350 *


ck - mb - 3 ctropnt - 0.40 *


although there was never any bacteria isolated from the blood you had some bacteria in the urine which you are being treated for .


she was obtunded and was thus intubated for airway protection .


10ml ns followed by 1ml of 100 units/ml heparin ( 100 units heparin ) each lumen qd and prn .


micro : sputum 12-27 : grm stn and cx negative


her oxygen saturation was 96% on ra but she was tachypneic to 31 .


13. heparin flush picc ( 100 units / ml ) 2 ml iv daily : prn 10 ml ns followed by 2 ml of 100 units / ml heparin ( 200 units heparin ) each lumen daily and prn .

lumen
heparin
heparin flush picc
heparin


pt was then initiated on the sepsis protocol .


her son reports that she then developed a headache and fevers started three days ago which were treated with tylenol .


cardiac enzymes were cycled and were normal .


ecg showed new diffuse twi in all leads .


post-intubation , the pt 's bp acutely dropped to 58/19 in the setting of propofol .


she may be started on asa , bb , statin by pcp as stephen .


she did complain of a left frontal headache .


4. shoulder fracture - patient is s/p a left hip fracture ( decision not to operate ) and a left shoulder fracture with hemiarthroplasty 11-14 .

shoulder fracture
s/p a left hip fracture
a left shoulder fracture


you were admitted with low blood pressure and fevers likely due to an infection .


15. dolasetron mesylate 12.5 mg iv q8h : prn


catheter tip 01-05 , ng .


stop linezolid on 2019-01-17 .


bld cx 12-26 , 12-27 , 12-28 , 12-31 - ng .


herpes simplex virus pcr - pnd


please complete a total 14 day course of linezolid .


statin was also deffered .


16. medication


picc line was removed empirically .


calcium - 6.2 * phosphate - 1.7 * magnesium - 0.9 *


pt was recently admitted to the hospital for orthopedics from 12-07 thorugh 12-14 with hypotension thought to be secondary to overdiuresis at hd.


5. papain - urea 544 287 0616 unit - mg / g ointment sig : one ( 1 ) appl topical daily ( daily ) .


tip could not be cultured due to contamination .


pt was then sent to the the hospital for orthopedics juan for further evaluation .


csf grm stn / cx : negative


pt is now transferred to the ficu for further care .


cxr , lp , ua and abdominal ct showed no sign of infection .


cortisol - 10.3


wbc - 9.0 rbc - 2.93 * hgb - 9.0 * hct - 29.7 * mcv - 101 * mch - 30.8 mchc - 30.4 * rdw - 24.1 *


8. metoprolol tartrate 25 mg tablet sig : 0.5 tablet po tid ( 3 times a day ) : hold for sbp < 100 , hr < 60 .


hypochrom - 3+ anisocyt - 3+ poikilocy - 1+ macrocyt - 3+ microcyt - 1+

anisocyt hypochrom macrocyt microcyt poikilocy


3. zinc sulfate 220 mg capsule sig : one ( 1 ) capsule po daily ( daily ) .


assumed to be secondary to trauma when moving patient into ambulance .


7. calcium acetate 667 mg tablet sig : one ( 1 ) tablet po tid w/ meals ( 3 times a day with meals ) .


he son also notes that she appeared to be working hard to breath .


cmed service was consulted and recommended wtd woulnd care and sling at all times .


given stress dose steroids empirically and sanchez stim showed cortisol of 9.3 --> 10.3 therefore steroids continued .


she received a total of 4 liters of ns then was started on levophed for continued hypotension .


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


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


she was found to be febrile to 101.9 and received levoflox and vancomycin .


9. tylenol 650 mg q4h prn


then , this morning she developed fatigue and did not eat well .


covered broadly with vancomycin , flagyl , and cefipime .


10. ondansetron 4 mg q6h prn


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


intubation for airway protection tunneled line change over wire 2019-01-08

airway protection
intubation
tunneled line change over wire


14. heparin flush cvl ( 100 units / ml ) 1 ml iv daily : prn


her dialysis was managed by renal service in house .


12. linezolid 600 mg iv q12h


7. pe ( 11-14 )- on heparin drip .


1. sepsis / id- started on sepsis protocol .


restared coumadin on 12-29 .


losartan / aspirin / lisinopril-hctz


11. warfarin 2 mg tablet sig : one ( 1 ) tablet po hs ( at bedtime ) : titrate dose to goal inr 03-15 .


10. insulin regular human 300 unit / 3 ml insulin pen sig : as directed subcutaneous four times a day : please administer 8 units glargine at dinner and regular insulin sliding scale as prescribed .

regular insulin sliding scale
glargine
insulin regular human


chief complaint : fever


9. fluconazole 200 mg tablet sig : one ( 1 ) tablet po q24h ( every 24 hours ) for 2 days .


heparin discontinued on 01-01 when inr was 2.0 .


69 y/o female wtih pmh significant for esrd on hd , type 2 dm , and recent pe resulting in pea arrest admitted through the juan with sepsis of unknown etiology .

esrd
pea arrest
sepsis
type 2 dm
recent pe


pea arrest
sepsis
type 2 dm
recent pe
esrd
pmh


2018-12-26 08:28 pm urine


this should be titrated after discharge for inr goal of 2-3 .


8. pvd :


continue to monitor for sign of infection .


6. ipratropium bromide 0.02 % solution sig : one ( 1 ) inhalation q4h ( every 4 hours ) .


9. left ue markedly more edematous than right ue , this could be from fracture , or there could be a clot , an abscess in the area also a possiblity .

a clot
an abscess in the area
more edematous
fracture


crp - 46.2 *


lactate - 1.8


right dialysis catheter ( 2018-11-05 ) was changed over a wire 2019-01-08 .


picc line placed 2019-01-08 , this should be discontinued immediately after pt finishes the linezolid course .


wound care consult given anasarca to prevent decub .


type - mix temp - 35.6 rates -/ 15 tidal vol - 500 peep - 5 o2 - 50 po2 - 34 * pco2 - 39 ph - 7.32 * total co2 - 21 base xs - -6

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


1. ascorbic acid 500 mg bid


tunnled catheter tip 01-08 - ngtd


ultrasound without clot .


glucose - 210 * urea n - 29 * creat - 3.2 * sodium - 139 potassium - 3.9 chloride - 112 * total co2 - 17 * anion gap - 14

potassium
urea n
glucose
sodium
creat
anion gap
total co2
chloride


continue elevation and tight dressing to lue >


c. diff b - negative


it is important that you complete the antibiotic course as prescribed .


infl a and b 12-27 : negative


dry gangrene of toes bilaterally w/ necrosis of the heels and posterior calf .


sed rate - 33 *


neuts - 65.2 lymphs - 25.2 monos - 6.0 eos - 3.3 basos - 0.4


- assist / con intubated - intubated


7. vitamin b complex 1 tab daily


robert the shortness of breath gets worse please return to emergency room .


6. neutra phos 2 tabs bid


4. riss


neuro - sedated .


8. coumadin - dose unknown


lactate - 1.6


3. humulin insulin 2 units qam


please continue to take all medications as prescirbed and follow up with all your appointments .


if you have fevers please contact your pcp or return to the emergency room .


5. pantoprazole 40 mg bid


2. folic acid 1 mg daily


do not appear infected .


skin breakdown between toes .


pressure ulcers under bilateral le right above the ankles .


plt count - 177


2+ pitting edema bilateral le .


cortisol - 9.3


10. access - left ij placed 12-26 in juan was discontinued during the hospitilization .


sodium 140 , potassium 5.2 , bun 38 , creatinine .7 , tsh 1.8 , digoxin level less than 0.2 .

tsh
digoxin level
creatinine
potassium
bun
sodium


1. hypotension - the patient was initially mildly hypotensive with systolic blood pressures in the 80s .


he was walking in the hall , dragging his intravenous pole when he tripped over the foot of the pole and lost his balance .


he was seen by his primary care physician the day before admission and complained of two weeks of increasing shortness of breath and fatigue , weight gain and abdominal fullness .

weight gain
abdominal fullness
fatigue
increasing shortness of breath


he did not sleep at all the night before and was extremely fatigued .


of note , this echocardiogram was performed when the patient was tachycardiac .


he was sent to the emergency department for further evaluation .


4. abnormal liver function tests - the patient had an isolated , elevated alkaline phosphatase with a confirmatory elevation in his gamma glutamyl transferase .

his gamma glutamyl transferase
abnormal liver function tests


the patient reported feeling at his baseline with chronic mild dyspnea on exertion until two weeks prior to admission .


white blood cell count 10.5 , hematocrit 38.1 , platelets 254 , inr 1.8 .

inr
platelets
hematocrit
white blood cell count


this is a 59 year old male with a past medical history significant for an atrioseptal defect repair at age 18 , congestive heart failure with an ejection fraction of 45% and a recent cardiac myocardial infarction , pulmonary hypertension and mitral regurgitation , and atrial fibrillation .

a recent cardiac myocardial infarction
pulmonary hypertension
congestive heart failure
mitral regurgitation
atrial fibrillation


his neurological examination at that time was nonfocal and the head was atraumatic without any evidence of a hematoma .


he denied fevers , chills , nausea or vomiting , chest pain or diaphoresis .

chills
nausea
fevers
diaphoresis
vomiting
chest pain


a computerized axial tomography scan of his head at that time did not reveal any extra or intracranial hemorrhage .


during this period he had also been weaned off of his digoxin starting early in february .


alt 14 , ast 31 , alkaline phosphatase 283 , total bilirubin 1.0 , amylase 71 , glucose tolerance test 317 .

glucose tolerance test
total bilirubin
amylase
ast
alkaline phosphatase
alt


over the two weeks prior to admission he had noticed an increasing heart rate from his baseline in the 60s to a heart rate in the 120s .


6. rectal bleeding - the patient has a history of rectal bleeding , ever since his brachytherapy for his prostate cancer .

his prostate cancer
rectal bleeding
rectal bleeding


he had also some increased shortness of breath and a 10 pound weight gain and new three to four pillow orthopnea with a dry cough .

some increased shortness of breath
a 10 pound weight gain
a dry cough
pillow orthopnea


in addition , plans were made to evaluate the patient 's cardiac arteries to determine if he had any component of ischemic cardiomyopathy .


there was some concern that the patient may have a partial biliary obstruction and the patient was sent for an magnetic resonance cholangiopancreatography to further evaluate the biliary system .


in addition the patient was started on verapamil since his heart rate had remained mildly tachycardiac in the low 100s .


digoxin 0.125 , discontinued one month prior to admission , toprol xl 100 mg daily , trazodone 50 mg once daily , lipitor 10 mg daily , diovan 40 mg daily , atrovent / albuterol prn , pulmicort , coumadin 2.5 mg daily , vitamin e , vitamin c , iron supplement .

vitamin e
coumadin
pulmicort
albuterol
atrovent
diovan
iron supplement
vitamin c
toprol xl
lipitor
trazodone
digoxin


the patient was loaded once again with digoxin and his beta blocker was increased to 100 mg of lopressor , three times a day .


moderate to severe 3+ mitral regurgitation and 3+ tricuspid regurgitation along with moderate pulmonary early systolic hypertension .


echocardiogram showed moderate dilated left atrium , no atrioseptal defect , severe global left ventricular hypokinesis with severe left ventricular systolic function and moderately dilated right ventricle .


an ultrasound of the right upper quadrant did not reveal any cholelithiasis or cholecystitis , however , an irregular hepatic contour was seen which is suggestive of underlying chronic liver disease .

underlying chronic liver disease
an irregular hepatic contour
any cholelithiasis
cholecystitis


there was global hypokinesis apical throughout the right ventricle and abnormal septal motion consistent with right ventricular volume overload .


magnetic resonance cholangiopancreatography did not reveal any evidence of biliary dilatation or of any obstructing pancreatic mass .

any obstructing pancreatic mass
biliary dilatation


it was felt that this potentially had lead to his atrial flutter and atrial fibrillation with rapid ventricular response .

rapid ventricular response
atrial fibrillation
his atrial flutter


initially he was treated with intravenous fluids with a dramatic response in his systolic blood pressure .


again seen was a slightly irregular contour of the liver with dilated hepatic veins suggesting chronic hepatic vascular congestion .


medicine


2. atrial fibrillation - the patient 's digoxin had been weaned off prior to his admission .


it was felt that he may have had some component of vascular congestion from his congestive heart failure as well as possibly some mild cirrhotic changes secondary to his previous alcohol use .

some mild cirrhotic changes
vascular congestion
his congestive heart failure


upon admission it was unclear whether or not the patient was volume overloaded or volume depleted .


serial cardiac enzymes negative .


atrioseptal defect repair in 1970 , cardiomyopathy , right-sided congestive heart failure , pulmonary hypertension , history of atrial fibrillation and atrial flutter , history of prostate cancer , status post brachytherapy , history of rectal bleeding , obstructive sleep apnea on cpap .

prostate cancer
atrial fibrillation
atrial flutter
right-sided congestive heart failure
rectal bleeding
cardiomyopathy
pulmonary hypertension
obstructive sleep apnea

atrioseptal defect repair
status post brachytherapy
cpap


the decision was made to have the patient undergo a cardiac catheterization to fully evaluate the hemodynamics to determine the etiology of the patient 's heart failure .


the patient was initially treated with intravenous fluids , however , subsequently he was diuresed when he became symptomatic and short of breath .


therefore the focus of treatment was changed to controlling his rate .


chest x-rays revealed evidence of congestive heart failure .


electrocardiogram showed atrial fibrillation with rapid ventricular response and atrial flutter .

atrial fibrillation
rapid ventricular response
atrial flutter


ace inhibitors , possible allergy to barium reported by the patient during a barium swallow 25 years ago .


however , subsequent it was determined that the patient 's hypotension may have been related to his rapid ventricular response and right heart failure .

the patient 's hypotension
his rapid ventricular response
right heart failure


the patient has been treated with argon laser therapy in the past for his rectal bleeding and it is recommended that he follow up with his gastroenterologist for repeat argon laser therapy .

argon laser therapy
repeat argon laser therapy


3. congestive heart failure - during the initial course of the patient 's admission , it was unclear as to whether or not he was volume overloaded or volume depleted .

congestive heart failure
volume depleted
volume overloaded


she has very mild left lower extremity pain which is largely unchanged .


2. congestive heart failure .


6. diabetes mellitus .


14. regular insulin sliding scale .


3. renagel 1600 mg p.o. t.i.d.


she received intermittent doses of lasix to assure overall negative intakes and outputs .


10. epogen 5000 units two times weekly , on monday and thursday .


8. protonix 40 mg p.o. q day .


internal medicine


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


3. acute renal failure .


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


of note , her blood pressure significantly improved in the 120s-130s which assured better perfusion in her kidneys .


9. magnesium oxide 800 mg p.o. b.i.d.


7. flagyl 500 mg p.o. t.i.d. for the next five weeks for osteomyelitis .


6. levofloxacin 250 mg p.o. q48 hours for the next five weeks for osteomyelitis .


2. warfarin 3 mg p.o. q h.s.


she progressed beautifully with physical therapy and occupational therapy and was able to ambulate with assistance .


5. osteomyelitis .


1. amiodarone 200 mg p.o. q day .


13. nph insulin 7 units in the morning and 5 units at night .


4. acute myocardial infarction .


her renal function significantly improved , and her discharge creatinine was 3.1 .


12. lasix 80 mg p.o. b.i.d.


1. coronary artery disease .


5. miconazole powder 2% t.i.d.


echo 11-02 : pre-bypass : left ventricular wall thickness , cavity size , and systolic function are normal ( lvef>55% ).


2015-11-13 06:15 am blood wbc - 8.8 rbc - 2.79 * hgb - 8.6 * hct - 25.4 * mcv - 91 mch - 30.9 mchc - 33.8 rdw - 15.6 * plt ct - 583 *