2012-06-08 09:30 am blood wbc - 10.1 rbc - 4.35 * hgb - 14.2 hct - 39.9 * mcv - 92 mch - 32.6 * mchc - 35.6 * rdw - 12.4 plt ct - 151

hct
mch
hgb
rbc
mcv
blood
wbc
mchc
rdw
plt ct


hep c


folate 1 mg qd


lescol 40 qd


2012-06-07 09:55 pm blood albumin - 3.9 calcium - 8.5 phos - 4.2 mg - 2.0


cmed : a+ox3 , mood " great ," affect approp , speech stuttering , linear tp , no si or hi


there was evidence of possible aspiration pneumonia on cxr , though he was extubated without incident on the am of transfer to the medicine floor .


neuro : no asterixis , cn ii-xii intact , 5/5 strength throughout , sensation to lt intact throughout , gait deferred


he was admitted to the cmed , intubated for airway protection and started on both a calcium and glucagon drip .

a calcium and glucagon drip
airway protection


cxr :


an endotracheal tube terminates just above the thoracic inlet approximately 6.5 cm above the carina .


2012-06-07 09:55 pm blood glucose - 108 * urean - 13 creat - 0.7 na - 146 * k - 3.7 cl - 109 * hco3 - 30 * angap - 11

cl hco3 angap blood glucose urean creat na k


there is a patchy area of increased opacity in the left retrocardiac region , which was not seen on the earlier study .


left costophrenic angle has been excluded from the study and cannot be assessed .


2012-06-08 09:30 am blood calcium - 10.4 * phos - 2.8 mg - 1.8


2012-06-07 09:55 pm blood alt - 44 * ast - 31 alkphos - 36 * totbili - 0.2


2012-06-07 09:55 pm blood plt ct - 175


the nasogastric tube terminates within the stomach .


there is no evidence of right pleural effusion or right pneumothorax .

right pleural effusion
right pneumothorax


per report , there were empty bottles of inderal and klonopin found at bedside , as well as 02-26 full bottles of geodon , gabapentin , lescol and paroxitine .

gabapentin geodon klonopin inderal lescol paroxitine


2012-06-07 09:55 pm blood pt - 12.8 ptt - 25.7 inr(pt) - 1.0


ng tube


1) endotracheal tube is slightly proximal in location , and could be advanced approximately 1.5 cm for more optimal placement .


- suicide precautions


his initial bp was 60/p with a pulse in the 60 s.


2012-06-08 09:30 am blood glucose - 115 * urean - 14 creat - 0.8 na - 142 k - 4.1 cl - 112 * hco3 - 26 angap - 8

urean hco3 angap cl creat na k blood glucose


2012-06-07 09:55 pm blood asa - neg ethanol - neg acetmnp - neg bnzodzp - neg barbitr - neg tricycl - neg

blood asa ethanol acetmnp bnzodzp barbitr tricycl


he was given 4 amps of calcium gluconate , and started on a calcium gtt .


- if hr drops , restart glucagon gtt


2) patchy left retrocardiac opacity which may be due to patchy atelectasis , aspiration , or early pneumonia .

early pneumonia
patchy left retrocardiac opacity
aspiration
patchy atelectasis


in the rita , the patient was intubated and given activated charcoal .


his urine and serum tox screens were notable only for benzos , otherwise negative .


he was also given 5mg of glucagon and started on a glucagon drip with good response .


narcissism


depressed


panic disorder


no history of head trauma or seizure disorder


depression


paxil 30 mg qd


bipolar d/o with one suicide attempt by overdose several years ago


propanolol 20 mg tid


followup radiograph suggested


neurontin 800 mg tid


agoraphobia


ziprasidone bid


ppx : sc heparin , bowel regimen , nicotine patch


protonix 40 mg qd


heent : ncat , perrl , eomi , no icterus , op clear , mmm , no tongue fasciculations


klonopin 2 mg tid


gen : caucasian man lying in bed , nad


vitals : 99.3 67 ( 60-70 ) 99/53 ( 90-100 s) 96% on ra 3.7l + los


femoral 2 + bilaterally , dorsalis pedis 1 + bilaterally , posterior tibial 1 + bilaterally , and radial 2 + bilaterally .

dorsalis pedis
femoral
radial
posterior tibial


weight preoperatively was 67 kg , at discharge is 70.9 kg .


temperature 98.4 , heart rate 78 and sinus rhythm , blood pressure 106/50 , respiratory rate 18 , oxygen saturation 97% on room air .

oxygen saturation
respiratory rate
temperature
heart rate
blood pressure
sinus rhythm


supple , no lymphadenopathy , no jugular venous distention , no thyromegaly .

thyromegaly
jugular venous distention
lymphadenopathy


rate of 91 , first degree av block , intervals .22 , .92 , .36 , with left ventricular hypertrophy .

first degree av block
left ventricular hypertrophy


admitted to bay state medical center hospital in 2012-10-22 in congestive heart failure at that time .


3. right hip replacement


moderate pulmonary hypertension , pa pressure 48/24 , 1+ mitral regurgitation , severe aortic stenosis with an lvedp of 19 and an ejection fraction of 43% .

severe aortic stenosis
1+ mitral regurgitation
moderate pulmonary hypertension

an ejection fraction
an lvedp
pa pressure


soft , nontender , nondistended , normal active bowel sounds , no hepatosplenomegaly .


include glucovance 5/500 one tablet twice a day , univasc 7.5 mg once daily , lasix 20 mg every other day , and aspirin 325 mg once daily .


sodium 141 , potassium 4.3 , chloride 108 , co2 25 , bun 24 , creatinine 0.8 , glucose 140 .

creatinine glucose sodium bun co2 chloride potassium


1. aortic stenosis


she was then referred to cardiothoracic surgery for aortic valve replacement .


at the time of transfer , the patient 's physical examination is as follows :


the patient did well in the immediate postoperative period , however , her blood pressure remained somewhat labile .


therapy .


warm and well perfused , with no cyanosis , clubbing or edema , no varicosities .


soft , nontender , nondistended , normal active bowel sounds .


white count 5.3 , hematocrit 43 , platelets 200 .


no carotid bruits were noted .


white count 4.1 , hematocrit 23 , platelets 144 .


incision with staples , open to air , clean and dry .


sodium 138 , potassium 4.9 , chloride 102 , co2 25 , bun 24 , creatinine 0.9 , glucose 309 .

sodium co2 chloride potassium glucose bun creatinine


warm and well perfused , with no cyanosis , clubbing or edema .


scattered rhonchi with diminished breath sounds in the bases .

scattered rhonchi
diminished breath sounds in the bases


she tolerated the operation well , and was transferred from the operating room to the cardiothoracic intensive care unit .


in summary , she had an aortic valve replacement with a #21 mosaic porcine valve .

a #21 mosaic porcine valve
an aortic valve replacement


therefore , she was continued on a neo-synephrine drip to maintain a systolic blood pressure greater than 110 .


regular rate and rhythm , s1 , s2 , with soft systolic ejection murmur .


laboratory data on 02-15 :


ranitidine 150 mg twice a day , enteric-coated aspirin 325 mg once daily , glucovance 5/500 one tablet twice a day , metoprolol 25 mg twice a day , furosemide 20 mg once daily for 14 days , potassium chloride 20 meq once daily for 14 days , colace 100 mg twice a day , niferex 150 mg once daily , percocet 5/325 one to two tablets every four hours as needed , ibuprofen 400 mg every six hours as needed .

colace
potassium chloride
niferex
ibuprofen
percocet
enteric-coated aspirin
ranitidine
metoprolol
glucovance
furosemide


her chest tubes were discontinued and , at the end of the day , she was transferred from the cardiothoracic intensive care unit to the floor for continuing postoperative care and cardiac rehabilitation .

her chest tubes
cardiac rehabilitation
continuing postoperative care


no known drug allergies .


significant for her father , who died at 50 years from myocarditis .


pulses :


aortic valve replacement .


heart rate 108 and regular , blood pressure 145/76 , respiratory rate 20 , height 5'2" , weight 141 pounds .

heart rate
respiratory rate
blood pressure
weight
height


chest x-ray is pending at the time of physical .


1. aortic stenosis status post aortic valve replacement with a #21 mosaic porcine valve

aortic valve replacement
a #21 mosaic porcine valve


electrocardiogram :


the patient was referred from an outside hospital with a chief complaint of increasing shortness of breath and tires easily with exertion .

tires easily
increasing shortness of breath


in addition , she was slow to awaken after her anesthesia was reversed , and in several attempts to wean from the ventilator , she developed a respiratory acidosis .


healthy-appearing woman , in no acute distress .


strength 5/5 in upper and lower extremities .


pupils equal , round and reactive to light , extraocular movements intact , anicteric , not injected .


her neo-synephrine drip was weaned to off .


she was again weaned from the ventilator , and successfully extubated .


no lesions or rashes .


she therefore remained on the ventilator throughout the day of postoperative day one .


referred to memorial hospital ( worcester ) for cardiac catheterization to further evaluate her aortic stenosis .


cardiac catheterization done on 01-07 showed an aortic valve area of .38 cm.sq. , with a mean gradient of 62 , and a peak gradient of 85 .

cardiac catheterization
an aortic valve area
a mean gradient
a peak gradient


her respiratory condition remained stable and , on postoperative day four , she was deemed stable and ready to be transferred to rehabilitation for continuing postoperative care and physical


via echocardiogram , found to have aortic stenosis .


clear to auscultation bilaterally .


regular rate and rhythm , s1 , s2 , with iii/vi blowing murmur .


2. diabetes mellitus type 2


3. right hip replacement


4. noninsulin dependent diabetes mellitus


temperature is 98.3 f. ; pulse is 76 ; blood pressure 113/52 ; breathing 18 ; 98% on room air .

breathing
temperature
pulse
blood pressure


on admission include a white blood cell count of 5.6 , hematocrit of 32.5 , platelets of 202 .

hematocrit
platelets
a white blood cell count


the patient was fully weaned from ventilatory support secondary to a persistent acidemia .


the patient has no cyanosis , clubbing or edema in extremities .


sodium of 140 , potassium of 3.5 , bun of 4 , creatinine of 0.6 , glucose of 137 .


no known drug allergies .


the patient had a recent admission earlier in the month and he was discharged on 2015-09-10 , after undergoing cardiac catheterization .


the patient is in no acute distress .


abdomen is soft and nontender .


cardiac catheterization demonstrates no significant disease in the coronary arteries .


mitral valve repair .


the patient was brought to the cardiothoracic intensive care unit in stable condition on minimal pressor support .


there is a persistent flow through an inferior branch of the left anterior descending to pa fistula and a persistent branch of the circumflex to pa branch fistula which anatomically were not suitable for coil embolization .

pa fistula
a persistent flow
the circumflex to pa branch fistula


two branches of an left anterior descending to pa fistula which was successfully coiled .


he tolerated this procedure well .


3. the patient will call for any fevers or difficulties with the wound care , and will be instructed with an interpreter present .

any fevers
difficulties with the wound care


it was equally up to 700 cc. an hour and a renal consultation was obtained .


2. colace 100 mg p.o. twice a day .


1. mitral regurgitation status post minimally invasive mitral valve repair .


there is no cervical lymphadenopathy .


he underwent a head ct scan to rule out intracranial pathology leading to diabetes insipidus .

diabetes insipidus
intracranial pathology


the patient 's serum and urine electrolytes indicated that this diuresis was appropriate .


he was successfully weaned off this support .


the patient is a 52 year old czech speaking gentleman with a history of severe mitral regurgitation .


he had developed some hematuria which has resolved .


this was treated with sodium bicarbonate and a swan-ganz was placed to provide close hemodynamic monitoring .


1. mitral valve regurgitation .


the patient is missing many teeth .


the patient was found to have stable hemodynamics with appropriate mixed venous saturations in the 70% range .


in addition , the patient 's early postoperative course had a tremendous urine output .


the patient 's urine output has decreased and his bun and creatinine remained normal .

his bun
creatinine
the patient 's urine output


he was then weaned off of ventilatory support and was successfully extubated .


3. nitroglycerin sublingual p.r.n.


the patient did have a slight bit of confusion early in post-extubation course which cleared .


this was significant for demonstrating no flow-limited disease in the coronaries but several fistulae

flow-limited disease in the coronaries
several fistulae


he reports severe dyspnea on exertion .


his lungs are clear to auscultation bilaterally .


for the past several years , the patient has continued to have significant exercise intolerance which has limited his ability to work .


1. lopressor 75 mg p.o. twice a day .


the patient 's foley was discontinued .


heart is regular rate and rhythm with a iii/vi systolic ejection murmur .


3. percocet one to two p.o. q. four hours p.r.n.


several of these were coil embolized during this admission .


1. atenolol 25 mg p.o. q. day .


ejection fraction was 60% .


chest x-ray shows no infiltrate or pneumothorax .


he tolerated this well , was sent home , and now returns for his mitral valve repair .


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


2. enteric-coated aspirin 325 mg p.o. q. day .


2013-10-29 11:37 am blood wbc - 11.4 *# rbc - 3.09 *# hgb - 9.1 *# hct - 27.5 *# mcv - 89 mch - 29.5 mchc - 33.3 rdw - 14.6 plt ct - 180

plt ct
blood
wbc
hgb
rbc
mch
hct
mchc
rdw
mcv


arthritis


you will need to follow up with your primary care physician / urologist prior to removal of your urinary catheter .


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


3. oxycodone - acetaminophen 5-325 mg tablet sig : 1-2 tablets po q4h ( every 4 hours ) as needed for pain for 30 doses .


mr. andersen is a 71-year-old male with worsening anginal symptoms who underwent catheterization that showed severe three-vessel disease .

worsening anginal symptoms
severe three-vessel disease


dm2 - dx 'd at the age of 48


cv : rrr , no m/r/g


2013-10-29 11:37 am blood pt - 16.2 * ptt - 29.0 inr(pt) - 1.7


heent : perrla , no carotid bruits


please call if you notice redness , swelling , or tenderness of your chest wound , or if it begins to drain pus .

your chest wound
pus
tenderness
swelling
redness


on post-op day #3 , the patient 's pacing wires were removed , and his lopressor was started .

the patient 's pacing wires
his lopressor


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


he was discharged home on post-op day #6 in stable condition with a foley catheter and leg bag .


7. tamsulosin 0.4 mg capsule , sust. release 24 hr sig : one ( 1 ) capsule , sust . release 24 hr po hs ( at bedtime ).


wash incision with mild soap and water , then pat dry .


avandia 8 mg daily


2013-10-29 01:09 pm blood glucose - 172 * urean - 11 creat - 0.9 na - 142 cl - 111 * hco3 - 22


2013-10-29 01:09 pm blood mg - 2.6


2013-10-29 11:37 am blood plt ct - 180


tonsillectomy around the age of 10


father died of colon cancer .


mother with pacemaker , alive at 91 years old .


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


8. metoprolol tartrate 25 mg tablet sig : 0.5 tablet po bid ( 2 times a day ).


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


5. rosiglitazone maleate 8 mg tablet sig : one ( 1 ) tablet po daily ( daily ).


the patient was taken to the operating room on 2013-10-29 for a cabg x5 .


he is presenting for revascularization .


htn


the patient tolerated this procedure well .


9. furosemide 20 mg tablet sig : one ( 1 ) tablet po every twelve ( 12 ) hours .


coronary artery disease


cabg x 5


abd : soft , nt/nd , nabs


on post-op day #4 , the patient failed the first of his void trials .


his central line and chest tubes were removed on post-op day #2 and was transferred to the floor in stable condition .


ext : cool , no varicosities , 1+ pedal pulses


11. potassium chloride 10 meq capsule , sustained release sig : two ( 2 ) capsule , sustained release po q12h ( every 12 hours ).


patient recorded as having no known allergies to drugs


please return to the hospital or call dr. alvarado 's office if you experience chills or fever greater than 101 degrees f.

chills
fever greater than 101 degrees f.


coronary artery disease requiring surgical intervention


metformin 500 mg two tabs bid


diovan 160 mg daily


glipizide 10 mg bid


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


awake and alert , nad


omeprazole 20 mg q pm


4. anterior instrumentation l3-l4 .


- mylanta 30 cc po q6 prn


5. autograft , bone morphogenic protein , and allograft .

bone morphogenic protein
allograft
autograft


- albuterol / atrovent nebs q4


the patient was continued on his iron supplements .


2. fusion at l3-l4 .


# anemia : his hct remained stable post-surgery .


3. vertebral spacer at l3-l4 .


1. partial vertebrectomy of l3 and l4 .


his dressings were changed by the nursing staff accordingly .


penicillins


wound care was consulted and made recommendations for ulcer care .


transfer from newton-wellesley hospital hospital for epidural abscess


12. fluconazole 200 mg tablet sig : two ( 2 ) tablet po q24h ( every 24 hours ) for 7 days .


6. acetaminophen 325 mg tablet sig : two ( 2 ) tablet po q6h ( every 6 hours ) as needed for fever or pain .


5. miconazole nitrate 2 % powder sig : one ( 1 ) appl topical tid ( 3 times a day ) as needed .


- metoprolol 50 mg po daily


- metformin 500 mg po bid


- vancomycin 1.5 gm q 12 hours


- glipizide 5 mg po bid


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


- insulin sliding scale


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


- pepcid 20 mg po daily


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


states he first developed back pain 5 weeks ago but was still able to ambulate with his cane .


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


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


pt states he has been receiving chemotherapy up until 1 week ago .


8. cepacol 2 mg lozenge sig : one ( 1 ) lozenge mucous membrane prn ( as needed ).


pt has h/o colon can to liver , s/p resxn with serosal implants in 9/03 .


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


20. insulin lispro ( human ) 100 unit / ml cartridge sig : one ( 1 ) subcutaneous four times a day : as directed by sliding scale-please see attached scale .

sliding scale-please
insulin lispro ( human )


73 yo m transferred from newton-wellesley hospital hospital for epidural abscess .


8. echocardiogram


7. incision and drainage


16. vancomycin in dextrose 1 g / 200 ml piggyback sig : one ( 1 ) intravenous q 12h ( every 12 hours ): to finish on 2020-05-12 .


14. bisacodyl 5 mg tablet , delayed release ( e.c. ) sig : two ( 2 ) tablet , delayed release ( e.c. ) po bid ( 2 times a day ) as needed .


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


6. debridement


13. oxycodone 10 mg tablet sustained release 12 hr sig : one ( 1 ) tablet sustained release 12hr po q12h ( every 12 hours ).


11. oxycodone 5 mg tablet sig : 1-2 tablets po every 4-6 hours as needed for pain for 14 days .


initially on vanc and cipro on friday but then seen by id who reccommended no abx but a bone biopsy , blood cx .


- cad s/p cabg x4 in ' 03 .


19. insulin glargine 100 unit / ml solution sig : four ( 4 ) units subcutaneous at dinner time .


- dm with neuropathy .


- worsening pain or weakness in your legs , loss of bowel or bladder function or any other concerning symptoms .

loss of bowel or bladder function
any other concerning symptoms
weakness in your legs
worsening pain


primary diagnosis : epidural abscess


18. heparin lock flush ( porcine ) 100 unit / ml syringe sig : two ( 2 ) ml intravenous daily ( daily ) as needed : 10 ml ns followed by 2 ml of 100 units / ml heparin ( 200 units heparin ) each lumen daily and prn .

heparin
ns
heparin
heparin lock flush ( porcine )


an mri was done and this showed a signal abno in l3 l4 ? disciitis vs osteo without a definitive epidural abscess .

a signal abno in l3 l4
disciitis
osteo
a definitive epidural abscess


- persistent r foot ulcer


heent : clear op , mm very dry .


neck : supple , no lad , no jvd


- hypercholesterolemia


he states he gives her one of his pensions and she helps him with medicines etc .


- colon cancer with mets to liver s/p resection 09-07 .


continue to take the antibiotics as directed .


currently pt denies sensory deficits or weakness .


states he is not able to walk because of severe pain .


take the pain medication as directed and do not drive while taking this medication .


gen : in nad , but winces in pain with movements of his back .


cxr also showed small pleural effusion and attempt was made to tap it , but pt did not tolerate the procedure and asked that it be deferred .


no bowel or bladder incontinence .


he did undergo a ct-guided aspiration / biopsy at the l3-4 disc space on 2020-03-11 and the pt was transferred to mediplex rehab hospital immediately following this .


stable , afebrile


you were diagnosed with an epidural abscess .


states pain is worst when he sits up or twists his back .


- epidural abscess


he was subsequently restared on vancomycin for corynebacterium in blood cx from fri ; followup cx has been ngtd .


- chest pain or shortness of breath


17. pepcid 20 mg tablet sig : one ( 1 ) tablet po once a day .


- fever > 102


well healed midline scar from chest down to pubis .


ext : no edema .


no hsm .


ii/vi sem at lsb with radiation to apex .


abd : pt very tense in abdomen ( states belly is fine , but he is weary of his back ).


na : 135 , k 4.5 , cl 96 , co2 27 , bun 12 , cr 0.7 , glu 167 , ca 8.4 , vanco trough 13 , wbc 5.3 , hct 32.0 , plt 330 , inr 1.0 .

k
vanco trough
inr
plt
hct
ca
glu
cl
co2
wbc
bun
cr


1 + dp pulses bl


no erythema or swelling noted .


dressing c/d/i over r le ulcer .


chest : port a cath in r chest , no erythema or tenderness .


back : + ttp of lumbar spine and paraspinal muscles , r > l .


no culture data was sent .


lungs : + crackles at l base > r base .


cxr ( youville hospital 2020-03-09 ): persistent unchanged l mid and lower lung field airspace disease with moderate l pleural effusion .


mri lumbar spine ( youville hospital 2020-03-10 ): l3-4 osteomyelitis , discitis , and epidural abscess .

epidural abscess
discitis
l3-4 osteomyelitis


# corynebacterium bacteremia : presumably corynebacterium in epidural abscess as well .

corynebacterium bacteremia
corynebacterium
epidural abscess


degenerative changes including multilevel central spinal stenosis .

degenerative changes
multilevel central spinal stenosis


he was continued on iv vancomycin throughout his course and had therapeutic troughs .


impression on the anterior aspect of the lower spinal cord at t11-12 by disc bulge .


addendum : findings are c/w paraspinous extension of infection anteriorly and laterally into the medial aspects of the psoas muscles bilaterally at the l3 and l4 levels .


73 yo m transferred from youville hospital with h/o colon cancer with known liver mets now with epidural abscess and corynebacterium bacteremia :

corynebacterium bacteremia
epidural abscess
colon cancer
known liver mets


# pleural effusion : the patient was noted have an effusion on cxr .


# epidural abscess : the patient was evaluated by orthopedic spine consult service and id .


the patient had no blood cultures to grow corynebacterium while hospitalized .


please see the operation notes for details about the surgeries .


the patient was briefly admitted to the icu for low hematocrit and hyponatremia immediately following the surgery but was then transferred back to the floor in stable condition .


the patient was started on diflucan .


# candidemia : the patient was noted to have a positive blood culture from 03-12 .


the patient will also wear a back brace at all times while out of bed .


a repeat ct was done showing nodular thickening along the right major and minor fissure , concerning for intrapleural tumor implants .

intrapleural tumor implants
nodular thickening


the patient had a picc line placed and will continue a 8 week course of antibiotics .

a picc line
a 8 week course of antibiotics


the tap was negative for malignant cells .


ip was consulted and did a thoracentesis .


ophthalmology was consulted and ruled out ocular spread .


outpatient course and pleurodesis if the pt becomes symptomatic 02-07 fluid accumulation .


the patient 's portocath was removed .


- lovenox 40 mg sc q24 for dvt ppx


- iron sulfate 300 mg po tid


the tip was culture negative .


- procrit 40,000 units sc q friday


the patient will get a total of a two week course of diflucan .


1. albuterol sulfate 0.083 % solution sig : one ( 1 ) inhalation q4h ( every 4 hours ) as needed .


- morphine 2-4 mg iv q3-4 prn


he was also seen by spine who repeated the mri and this showed l3-4 osteomyelitis and discitis and an epidural abscess , 5cm .

discitis
an epidural abscess
l3-4 osteomyelitis


ip reviewed the films and recommended continue oncologic care according to


# foot ulcer : diabetic ulcer s/p surgery but never healed .


she received a 7 day course of amoxicillin for which enterococcus was sensitive but klebsiella unknown .


rifaximine 200 mg tid


lactulose 30 cc qid titrated to 3-4 bm / day


pt previously diagnosed with hepatorenal and was started on midodrine , octreotide and albumin ; these were


the hospitalisation was also significant for mild dic for which she received cryoglobulins and uti (+ enterococcus and + klebsiella ).


her creatinine continued to increase , likely due to her worsening liver failure .


a/p : 48 yo morbidly obese woman with hcv cirrhosis c/b encephalopathy , esophageal varices and partial vein thrombosis ( but no hx of sbp ) presents with increasing abdominal girth likely secondary to ascites .

sbp
hcv cirrhosis
encephalopathy
esophageal varices
partial vein thrombosis
ascites
increasing abdominal girth


hcv cirrhosis c/b esophageal varices , ascites , partial portal vein thrombosis

hcv cirrhosis
esophageal varices
ascites
partial portal vein thrombosis


protonix 40 mg po qd


admitted for diagnostic / therapeutic paracentesis and then transferred to the icu for hypotension , confusion and anemia .


syndrome ( cr 3.3 at its worst ) which resolved prior to her discharge .


also , due to worsening renal function , she was started on octreotide / midodrine / albumin for hepatorenal


2. moderate ascites .


# liver cirrhosis : meld score of 34 on admission .


while her discharge summary maintains that she was continued on furosemide / spirinolactone / propranolol , the patient did not receive any scripts on discharge and as a result did not take these medications .

furosemide
propranolol
spirinolactone
these medications


urine lytes with na of 10 indicating either pre-renal or hepatorenal .


fluid challenge with 36gm of albumin , one unit of prbcs and 2l of ns .


her mental status also had decreased from admission and her urine output was minimal , 225cc over the past 12 hours .


temp noted to be low at 94 and she was placed on bear hugger which improved temp to 96.7 .


will check creatinine this afternoon .


she was recently hospitalised from 02-23 / 03-04 for abdominal discomfort at which time she underwent paracentesis that ruled out sbp and relieved her abdominal pain .

sbp
her abdominal pain
abdominal discomfort


creatinine this am was 1.9 from 0.9 yesterday .


she was placed on pressors to maintain a map > 55 .


she received 2 units of plts and 1 unit of prbc s.


in the am , she was found to have a hct of 24 , down from 32 and plts 35 , down from 72 .


her bp was then noted to be decreased at 80/40 which improved mildly to 90/30 with 1.5l of ns .


once the decision was made to withdraw care , the pressors were discontinued .


# anemia : hct dropped following the tap and there was concern for bleed into her abdomen .

bleed into her abdomen
hct dropped
anemia


she received 36gm of albumin following the tap .


she received one unit of prbc s.


she then had 6l of non-bloody ascitic fluid removed without complication .


her bp on admission was 120/70 and remained stable following the tap .


ct of the abdomen and pelvis showed no evidence of bleed .


over the next several hours , pt complained of abd pain but this resolved on its own without medication .


her hematocrit remained stable at 24-26 following the acute drop.


# arf : creatinine has increased from 0.9 on admission to 1.9 on admission to icu .


she denied abd pain , fevers , chills .


she was admitted for a large volume paracentesis but her inr on admission was 3.8 .


she received 4units of ffp which decreased her inr to 2.2 and then 2 more units during the tap .


# recurrent ascites : on the medical floor , pt had a large volume paracentesis ( 6 liters ) followed by replacement with albumin .

replacement with albumin
a large volume paracentesis


she also described sob , nausea , worsening lower ext edema .


# hypotension : pt became hypotensive following the large volume paracentesis despite replacement with albumin .

the large volume paracentesis
replacement with albumin


this was thought to be 04-09 the large volume tap verses sepsis though she had no other evidence of sepsis .


47 female with h/o hcv cirrhosis compocated by encephalopathy , ascites , and h/o portal vein thrombosis ( right anterior portal vein ) and portalcaval shunt ( reversed flow in main portal vein ) presents from liver clinic with increasing abdominal girth .

portal vein thrombosis
encephalopathy
hcv cirrhosis
ascites
increasing abdominal girth


2015-03-26 10:10 am blood pt - 23.0 * ptt - 63.2 * inr(pt) - 3.8


2015-03-26 10:10 am blood glucose - 76 urean - 17 creat - 0.8 na - 129 * k - 3.9 cl - 101 hco3 - 19 * angap - 13

creat urean glucose blood na k hco3 angap cl


2015-03-26 10:10 am blood alt - 33 ast - 65 * alkphos - 70 totbili - 30.3 * dirbili - 20.8 * indbili - 9.5

blood alt dirbili ast indbili totbili alkphos


2015-03-26 10:10 am blood neuts - 68.3 bands - 0 lymphs - 19.8 monos - 10.6 eos - 1.1 baso - 0.2


2015-03-26 10:10 am blood wbc - 8.1 rbc - 3.69 * hgb - 11.0 * hct - 32.4 * mcv - 88 mch - 29.8 mchc - 33.9 rdw - 26.0 * plt ct - 72 *#

blood
mcv
wbc
rbc
mchc
rdw
plt ct
hgb
hct
mch


paracentesis


2015-03-26 10:10 am blood hypochr - 1 + anisocy - 2 + poiklo - 2 + macrocy - 2 + microcy - normal polychr - normal ovalocy - occasional target - occasional schisto - occasional tear dr clark

target blood microcy macrocy ovalocy polychr poiklo anisocy hypochr schisto


4u ffp


3. cholelithiasis without evidence of acute cholecystitis .


increasing abdominal girth


decision was made by the family and the medical team to withdraw care .


1. small cirrhotic liver with what appears to be a portocaval shunt .


morphine / histamine h2 inhibitors / heparin agents

heparin agents
morphine
histamine h2 inhibitors


2015-03-26 10:10 am blood ammonia - 39


no thrush .


2015-03-26 10:10 am blood albumin - 3.1 *


after it was explained that the pt 's prognosis was very poor given that she was not a transplant candidate , the


cardiac : rrr , no murmurs


abdomen : obese , soft , mildly distended dull to percussion throughout , no tenderness , liver non-palpable due to large volume of ascited

mildly distended
obese
large volume of ascited
tenderness
liver non-palpable
dull


morbid obesity


she also underwent us that revealed patent portal and hepatic vessels .


expired


pt became more encephalopathic during her hospital course .


extremities : 05-09 + pretibial edema extending above knee r > l , no asterixis .


no palmar erythema


she was not a transplant candidate due to her obesity .


she had no evidence of sbp .


4. no hydronephrosis .


5. borderline splenomegaly .


sickle cell trait


physical exam : t 95 , bp 120/70 , hr 82 , rr 20 , 96% ra wt 301.6 lb


recent cholecystitis 08-10


h/o gastritis


heent : + scleral icterus .


she began enteral feeds on day of life #2 advancing to mother 's breastmilk 30 with promod at 150 cc / kg / day .


6. immunizations recommended -


lungs : breath sounds clear and equal bilaterally , no retractions .


1. tuberculosis , mother was treated in 2001 according to chart with subsequent negative chest x-ray , and


synagis respiratory syncytial virus prophylaxis should be considered from october through april for infants who meet


heart : regular rate and rhythm , no murmur , normal s1 and s2 , pulses 2 +.


the patient was initially started on d10 / w at 80 cc / kg / day .


the patient had a weight of 1400 gm , length 41.5 cm and head circumference of 29.25 cm .


thickening consistent with trisomy 21 in the b co-twin .


3. with chronic lung disease .


2. cardiovascular - the patient has been cardiovascularly stable without murmur .


after some debate , we concluded that vetrano was not at unusually high risk from rsv , but that her sister might be .


baby received parenteral nutrition and lipids for four days .


abdomen : soft , nondistended .


the pregnancy was complicated by twin gestation and by polyhydramnios with apparent duodenal atresia and nuchal

duodenal atresia
polyhydramnios
twin gestation


vetrano probably does not need synagis at least until her sibling is discharged from the hospital .


without hepatosplenomegaly , without masses .


influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease once they


the baby received no blood products .


2. medications - poly-vi-james 1 cc p.o. q. day ; iron or fer-in-james 0.2 cc p.o. q. day to give 2 mg / kg / day

fer-in-james medications iron poly-vi-james


group b streptococcus status unknown .


no fever , no fetal tachycardia , rupture of membranes at delivery .

fetal tachycardia
fever
rupture of membranes


sepsis risk factors :


anterior fontanelle , soft and flat , palate intact , nondysmorphic features .


rebound bilirubin 6.4 .


3. car seat screening - passed .


4. gastrointestinal , genitourinary - peak bilirubin 8.5 , phototherapy times 24 hours .


4. state newborn screening - last on 2009-01-07 , all within normal range .


5. immunizations received - hepatitis b vaccine given 2009-01-22 .


initial complete blood count with white blood cell count 14 , hemoglobin 21.6 , hematocrit 62.9 , 65 neutrophils , no bands , 28 lymphocytes .

initial complete blood count
white blood cell count
hematocrit
hemoglobin
lymphocytes
neutrophils
bands


well-appearing female without distress on admission to the newborn intensive care unit .


5. hematology - most recent hematocrit was 42.8 on 50-05-25 .


1. feeds - breastfeeding ad lib , supplementing with enfamil 24 or breastmilk 24 cal / oz made with 1 tsp of enfamil powder per 100 cc of breastmilk .


maternal hypertension was noted in the doctor 's office and mom was referred to nonreassuring fetal tracing , necessitating an urgent cesarean section .


6. infectious disease - no sepsis risk factors .


apgars were 8 at one minute and 8 at five minutes .


twin #1 cried spontaneously at birth , was bulb suctioned and received blow-by oxygen .


a follow up examination is recommended in six to eight months .


3. fluids , electrolytes and nutrition - birthweight was 1400 gm , 25th percentile .


twin #1 was noted to be in a breech presentation .


baby is presently tolerating mother 's breastmilk with enfamil powder to make 24 cal / oz at 130 cc / kg / day .


breath sounds , clear and equal , without retractions , respiratory rate 30 s to 60 s.


amniocentesis was not performed .


8. sensory - audiology , hearing screening was performed with automated auditory brain stem responses .


on day of life #1 , caffeine was started .


reach six months of age , before this age the family and other caregivers should be considered for immunization against


blood cultures negative .


positive suck , positive grasp .


1. respiratory - gerardo was initially placed in nasal cannula oxygen to maintain oxygen saturation greater than 94 .


influenza to protect the infant .


baby passed hearing test on 2009-01-21 .


maternal blood type 0-positive , dat negative , negative , rpr nonreactive .


no hypoglycemia issues noted .


1. prematurity , former 32 4/7 weeks , twin #1


2. infertility .


caffeine was discontinued on day of life #19 .


2. rule out sepsis


she was also to obtain a second opinion regarding the question of possible surgical management .


her abdomen was notable for voluntary guarding but no involuntary guarding or rebound , mild right lower quadrant tenderness greater than left lower quadrant , nondistended .

involuntary guarding
nondistended
mild right lower quadrant tenderness
rebound
voluntary guarding


she was continued on her antibiotics , and was afebrile until hospital day number five , when she had a temperature spike to 102.3 .


this is a 49-year-old gravida iii , para ii , status post uterine artery embolization on 2009-01-07 due to uterine fibroids , with continued abdominal pain and ct scan revealing fluid and gas in the endometrial cavity .

continued abdominal pain
fluid and gas in the endometrial cavity
uterine fibroids


temperature 100.4 , pulse 108 , respirations 20 , blood pressure 110/70 , oxygen saturation 100% on room air .

pulse
temperature
oxygen saturation
respirations
blood pressure


the patient requested an outside second opinion , as she was reluctant to undergo hysterectomy at this time .


her sedimentation rate was elevated at 110 .


she has had continuing vaginal discharge , and was diagnosed with bacterial vaginosis one day prior to admission , and was given a prescription for flagyl .

continuing vaginal discharge
bacterial vaginosis


the patient was to have a repeat ct scan in one week .


possible drainage of the abscess vs. hysterectomy .


she also complained of some loose stools on the day of admission , no nausea or vomiting .


discussion was had at this time with the patient regarding whether or not this represented an infected abscess vs. post-surgical change .

post-surgical change
an infected abscess


she was discharged to home on hospital day number eight , on oral antibiotics .


the patient was admitted and was initially started on intravenous ampicillin , gentamicin and clindamycin .

intravenous ampicillin
gentamicin
clindamycin


she went to her primary care physician 's office on the day of admission complaining of abdominal pain , which she stated was constant but intermittently sharper at times .


history of herpes simplex virus , last outbreak in 2000 .


her temperature was 100.4 in the office , and she had no chills .


on hospital day number three , her blood cultures came back positive in the anaerobic culture for gram-positive cocci in pairs and clusters .

her blood cultures
the anaerobic culture


dilatation and curettage x 1 for sab .


at this time , an infectious disease consult was obtained , and the recommendation was to discontinue the ampicillin , gentamicin and clindamycin , and start her on intravenous unasyn .

the ampicillin
gentamicin
clindamycin
intravenous unasyn


her electrolytes were within normal limits .


some spotting on the day prior to admission , but not a normal period .


cesarean section x 2 , dilatation and curettage x 1 , neck fusion after motor vehicle accident , shoulder surgery after motor vehicle accident .

shoulder surgery
cesarean section
neck fusion
dilatation and curettage


her white blood cell count was 12.8 , with a normal differential .


her initial white blood cell count was 11.3 , with a normal differential .


cesarean section x 2 , spontaneous abortion x 1 .


repeat blood cultures were sent .


she noted increasing abdominal pain two days prior to admission , which became more severe on the day prior to admission .


she was sent for a ct scan of her abdomen , which revealed fluid and question of gas in the endometrial cavity , and she was sent to pinewood , norfolk for treatment and admission .


fibroid uterus status post embolization on 2009-01-07 .


further identification revealed staphylococcus coag-negative , which was sensitive to gentamicin and clindamycin .


lupron x three months prior to embolization .


she was maintained on intravenous antibiotics .


her uterus and adnexa were difficult to assess secondary to voluntary tensing of her abdomen .


flagyl .


she underwent a pelvic ultrasound and an abdomen and pelvis ct , which revealed continued air in the endometrial cavity vs. in the fundal fibroid .

continued air in the endometrial cavity
the fundal fibroid

an abdomen and pelvis ct
a pelvic ultrasound


her pelvic examination was notable for some brownish discharge .


the patient is a 49-year-old gravida iii , para ii , who was sent from her primary care physician 's office secondary to lower abdominal pain .


the patient is status post uterine artery embolization on 2009-01-07 secondary to fibroids .


no history of abnormal pap smears .


in general , she was in no acute distress .


please give patient medications as prescribed and read warning labels carefully .


if signs and symptoms of infection , such as fevers / chills , purulent discharge from wound / incision site , increased redness , increased pain , please call or go to the emergency room .


stage 2 of the surgery will be done in 3 weeks .


trazodone / ambien / sinequan


7. atorvastatin 10 mg tablet sig : one ( 1 ) tablet po hs ( at bedtime ).


6. divalproex sodium oral


please clean incision site with normal saline or clean water three times a day and place antibiotic ointment ( given ) on top of wound .


1. paroxetine hcl 10 mg tablet sig : one ( 1 ) tablet po am ().


8. oxybutynin chloride 5 mg tablet sig : one ( 1 ) tablet po qpm ( once a day ( in the evening )).


10. bacitracin-polymyxin-neosp hc ointment sig : one ( 1 ) topical three times a day .


most importantly , the patient must be watch one-on-one so that she does not pick at her wound .


right nose / ala reconstruction using right cheek advancement and forehead local flap

right cheek advancement
forehead local flap
right nose / ala reconstruction


extremities : no edema , cyanosis , full range of motion


gen : no acute distress , able to communicate and follow orders


she went to surgery the next morning and tolerated the surgery well .


bipolar disorder


acquired defect from basal cell carcinoma resection


on presentation , pt was afebrile with normal vital signs


mental retardation


lungs : clear to asculation


ms. marshall is a 64-year old , mentally retarded , female who presented with an aquired defect of the right nasal ala and medial cheek region after basal cell carcinoma was resected by dermatology .


however , she was slow to awake from anesthesia , and was admitted to the cmed ccu observation .


upon admission , the patient was pre-op 'd and made npo / ivf .


abdomen : soft , non-tender , non-distended


diabetes


head and neck : 5 cm circular full thickness defect at the junction of the right ala and cheek


3. divalproex sodium 500 mg tablet , delayed release ( e.c. ) sig : one ( 1 ) tablet , delayed release ( e.c. ) po qam ( once a day ( in the morning )).


2. multivitamin capsule sig : one ( 1 ) cap po qam ( once a day ( in the morning )).


stage two of her surgery will be done in 3 weeks .


aquired deformity of the right ala / nose and medial cheek from basal cell carcinoma resection


9. hydrocodone-acetaminophen 5-500 mg tablet sig : 1-2 tablets po q4h ( every 4 hours ).


she will be discharged today back to her nursing home in good condition , on pain meds , antibiotics , and with anticipated 1:1 watch .


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


her wound has remaind dry and closed , without evidence of infection or breakdown .


she was transfered to the floor post-op day 2 where she had been afebrile with normal vitals , making good urine , and tolerating a regular diet .


5. triamcinolone acetonide 0.1 % cream sig : one ( 1 ) appl topical bid ( 2 times a day ).


95 yo f with mmp who sustained a mechanical fall down stairs resulting in a hip and arm fracture .

mmp
a hip and arm fracture
a mechanical fall


ct of the abdomen without iv contrast : there are bilateral pleural effusions , right greater the left ; there is compressive atelectasis at the left lung base .


neither iv nor oral contrast were used .


technique : a multidetector scanner was used to obtain contiguous axial images from the lung bases to the pubic symphysis .


lipid / cholesterol triglyc hdl chol/hd ldlcalc

chol/hd hdl ldlcalc triglyc cholesterol lipid


indication : 94-year-old woman with mental status changes , now with abdominal pain and hypertension .

abdominal pain
hypertension
mental status changes


contraindications for iv contrast : renal failure


7) gi : ms. pimental is an unfortunate 95 year old woman , status post a recent fall necessitating right orif of the hip and right wrist fracture orif , who was in the hospital for this event , when it was noted that she had abdominal pain , distention and coffee ground emesis with worsening mental status and renal failure .

right wrist fracture
worsening mental status
abdominal pain
distention
renal failure
coffee ground emesis
a recent fall


ct of the pelvis without iv contrast : as previously noted , there is a small amount of free fluid surrounding the right colon , tracking along the mesentery and into the pelvis .


the remainder of the bowel loops are fluid filled , and nondilated .


a catheter is seen entering the left inguinal region and coursing along the iliac vessels , terminating in the left pelvis .


osseous structures are remarkable for degenerative changes of the spine , and a fracture of the proximal right humerus , with orthopedic hardware causing beam hardening artifact .


ext - 2 + edema to knees , warm 2 + pulses , pain in r arm and r hip


2. bilateral pleural effusions , right greater than left , with left-sided compressive atelectasis .

bilateral pleural effusions
left-sided compressive atelectasis


2013-05-18 06:00 pm glucose - 188 * urea n - 48 * creat - 1.3 * sodium - 138 potassium - 4.0 chloride - 106 total co2 - 21 * anion gap - 15

anion gap
creat
urea n
glucose
sodium
chloride
total co2
potassium


10. history of lower gastrointestinal bleed in 2009-06-05 .


92 year old woman with ms changes , abd pain hypotension and bloody lavage on lovenox+asa

ms changes
bloody lavage
abd pain
hypotension


11. spinal stenosis


2013-05-18 06:00 pm pt - 13.3 ptt - 26.4 inr(pt) - 1.2 ekg - nsr 64 , 1st deg block , lad , new twi inf/lat leads , new st depressions v4-6

lad
1st deg block
new twi inf/lat leads
new st depressions v4-6


patient denies cp , sob , light headedness , or dizziness prior to of after the fall .

sob
cp
light headedness
the fall
dizziness


chemistry totprot albumin globuln calcium phos mg uricacd iron cholest

calcium cholest albumin uricacd mg globuln totprot iron phos chemistry


a small amount of nondependent free air is seen in the anterior aspect of the abdomen .


2013-05-19 09:20 am 1603 - 5419 ldl(calc) invalid if trig > 400 or non-fasting sample lab use only greenhd


a dual chamber pacemaker is seen with leads terminating in the right atrium and right ventricle .


nasogastric tube is seen coiling in the stomach , with its tip at the pylorus .


hemogloblin fractions ( cooximetry ) hgb calchct o2 sat cohgb methgb

methgb
calchct
hgb
o2 sat
cooximetry
hemogloblin fractions
cohgb


blood gases type temp rates tidal v peep fio2 o2 flow po2 pco2 ph calhco3 base xs aado2 req o2 intubat vent


there are coronary vascular calcifications .


the mid-distal lad was underfilled initially but was without obstructive disease .


calcium freeca


ct abdomen w/o contrast 2013-05-23 5:46 pm


multiorgan failure


tylenol


imdur 60 mg qdau


1. exploratory laparotomy with drainage of intra-abdominal abscess and peritonitis with gross soilage with bile and gastric contents .


2. examination under anesthesia with placement of splint , right elbow .


duodenal perforation


lasix alt 40 mg and 20 mg qday


continue to deteriorate spiking fevers with ventilatory support on pressors to hold the bp. with no improvement in mental staus was made cmo 5/20/5 .


glipizide 5 mg qday


asa 325 mg qday


levothyrox 50 mcg qday


blood gas


nicholas seizures , no loc , no head or neck trauma .

loc
head or neck trauma
nicholas seizures


5. placement of a right femoral arterial line .


90 yo f with mmp ( see below ) who sustained a mechanical fall down stairs resulting in a hip and arm fracture .

a hip and arm fracture
mmp
a mechanical fall


4. anemia , transfusion dependent every three months .


enzymes & bilirubin alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili

ast alt ld(ldh) ck(cpk) totbili amylase dirbili alkphos enzymes bilirubin


4. tube gastrostomy .


2. exposure and wide drainage of perforated posterior duodenal ulcer with internal and external drainage .

wide drainage
internal and external drainage
exposure


3. feeding jejunostomy .


renal & glucose glucose urean creat na k cl hco3 angap


8. chronic renal insufficiency with a b/l creatinine of 1.4 .


9. history of syncope and first degree a-v heart block with beta blocker therapy .


12. pacemaker - ddd dual chamber rate response pacemaker 2011-08-22 for symptomatic bradycardia


ct scan was obtained and this revealed free air and massive ascites .


t 96.0 bp 177/61 p 70 r 18 o2 97 on ra


2) cv - patient has cad and chf with a low hct and major trauma .


basic coagulation ( pt , ptt , plt , inr ) pt ptt plt smr plt ct inr(pt) lplt

pt
plt
ptt
inr(pt)
pt
ptt
lplt
plt smr
plt ct
inr
basic coagulation


gen - somnolent , confused


3) anemia - patient transfusion dependant with a baseline of 28 .


whole blood , miscellaneous chemistry glucose lactate na k cl calhco3

lactate
k
cl
glucose
calhco3
miscellaneous chemistry


5) dm - glipizide , iss


4) gerd - ppi


6) pmr - cont prednisone


hip fracture


patient recorded as having no known allergies to drugs


3. feeding jejunostomy .


4. tube gastrostomy .


5. polymyalgia rheumatica .


ct of head and neck neg for fx , bleed , and dislocation .


1. closed reduction of right hip with open placement of dynamic hip screw , right hip .


presented to taunton and found to have r humerus and r hip fx .


red cell morphology hypochr anisocy poiklo macrocy microcy polychr

polychr
anisocy
poiklo
hypochr
microcy
macrocy
red cell morphology


pt underwent surgery on 05-23


1. coronary artery disease status post non-st-elevation myocardial infarction in 2009-05-05 , status post cardiac catheterization with left anterior descending artery stent placement in 05/2001 .

coronary artery disease
non-st-elevation myocardial infarction


complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct

mch
rbc
complete blood count
hgb
plt ct
rdw
hct
wbc
mchc
mcv


1. exploratory laparotomy with drainage of intra-abdominal abscess and peritonitis with gross soilage with bile and gastric contents .


2. chf with an ejection fraction of 40-45% 02-09


differential neuts bands lymphs monos eos baso atyps metas

metas baso lymphs monos neuts bands atyps eos differential


hct 28 b/l


4. successful ptca and stenting of the proximal lad with overlapping 2.25 x 13 mm and 2.25 x 18 mm hepacoat stents with no residual stenosis or dissection and normal flow ( see ptca comments ).


new inferior and inferolateral wall motion abnormalities with more severe mitral regurgitation present .


resting regional wall motion abnormalities include inferolateral , inferior and mid septal hypokinesis .


1. coronary angiography demonstrated single vessel disease in a right dominant system .


the left atrium is elongated .


cath 2001


6. hypertension .


2013-05-18 06:00 pm plt smr - normal plt count - 216


2013-05-18 06:00 pm hypochrom - 1 + anisocyt - normal poikilocy - normal macrocyt - normal microcyt - normal polychrom - normal

polychrom microcyt poikilocy hypochrom anisocyt macrocyt


2013-05-18 06:00 pm neuts - 87.9 * bands - 0 lymphs - 6.3 * monos - 5.7 eos - 0.1 basos - 0


2013-05-18 06:00 pm wbc - 14.9 *# rbc - 2.91 * hgb - 8.5 * hct - 24.7 * mcv - 85 mch - 29.3 mchc - 34.5 rdw - 14.6


1. one vessel coronary artery disease .


5. the mitral valve leaflets are mildly thickened .


2013-05-18 06:00 pm ck(cpk) - 32


2013-05-18 06:00 pm ck-mb - notdone


7. hypothyroidism .


4. the aortic valve leaflets ( 3 ) are mildly thickened .


toprol xl 25 mg qday


famotidine 20 mg qday


fe so4 325 mg qday


3. diabetes type 2 .


2. moderately elevated right and left sided filling pressures .


2013-05-24 04:31 am art 36.4 16 / 662-15484 * 7.26 * 16 * -10


2013-05-24 07:58 am art 102 36 7.26 * 17 * -9


3. successful stenting of the proximal lad .


the dominant rca was a large vessel with no significant disease .


3. left ventriculography was not performed due to the presence of moderate renal insufficiency ( creatinine 1.6 ).


moderate pulmonary hypertension was present with a pa of 52/28 .


the cardiac index was preserved at 3.0 l / min / m2 .


the lad had serial 90% lesions proximally , involving the origin of the first diagonal , which was occluded and filled via left to left collaterals .


the non-dominant circumflex system had no hemodynamically significant stenoses .


2. resting hemodynamics revealed elevated right and left sided filling pressures with a mean ra pressure of 12 mm hg and a mean wedge pressure 24 mm hg .

a mean ra pressure
resting hemodynamics
a mean wedge pressure


fall was witnessed by daughter .


1. the left atrium is moderately dilated .


echo 02-09


2. the left ventricular wall thicknesses are normal .


there is mild regional left ventricular systolic dysfunction .


the left ventricular cavity size is normal .


overall left ventricular systolic function is mildly depressed .


she fell on her r side and had a great deal of pain in her r arm and hip .


multiple trauma


3. right ventricular chamber size is normal .


1 ctropnt > 0.10 ng/ml suggests acute mi


other enzymes & bilirubins lipase


compared with the findings of the prior study ( tape reviewed ) of 2009-06-05 , the lv function has improved with an improvementt in function of the apex , septal and anterior walls .


right ventricular systolic function is normal .


cpk isoenzymes ck-mb mb indx ctropnt


prednisone 5 mg qday


chemistry


lisinopril 5 mg qday


1. a small amount of free air and free fluid in the pelvis and abdomen , mostly along the right pericolic gutter and surrounding the ascending colon , concerning for perforation .


other bowel loops are unremarkable on this limited study .


3. right proximal humeral fracture status post fixation .


- transfuse 2 units today , with lasix


the study and the report were reviewed by the staff radiologist .


a small amount of free air is seen in the nondependent portion of the pelvis .


assist / con1 intubated


she also has new changes on ekg .


vascular calcifications are seen in the abdominal aorta and iliac arteries .


cor - rrr , no m/r/g


7. there is no pericardial effusion .


subcutaneous edema is noted in the lower abdomen and pelvis .


on pressor to hold mean 60 .


patient has injuries to her shoulder and hip .


a nasogastric tube is seen coiling in the stomach .


1) s/p fall - unlikely to be mechanical in nature .


allowing for the limitations of this noncontrast study , the liver , pancreas , adrenals , stomach are unremarkable .


a 1.8 cm exophytic renal cyst is seen on the left .


a similar lesion is seen on the right , measuring 2.2 cm .


the aorta is normal in caliber , with vascular calcifications .


a small amount of free fluid is seen tracking around the liver , right pericolic gutter , along the mesentery and surrounding the right colon , which is collapsed .


no aortic regurgitation present .


ct abdomen w/o contrast ; ct pelvis w/o contrast

ct pelvis w/o contrast
ct abdomen w/o contrast


abd - s/nt/nd +bs


expired


6. there is moderate pulmonary artery systolic hypertension .


reason : please eval for perf / ischemic bowel


moderate ( 2 +) mitral regurgitation is seen .


please eval for perf / ischemic bowel


sodium 139 , potassium 3.8 , chloride 101 , bicarb 26 , bun 9 , creatinine 0.7 , glucose 141 , albumin 4.1 , calcium 8.9 , ldh 665 , ast 44 , alt of 57 , amylase 41 , ck 32 .

albumin calcium potassium chloride bun sodium ldh amylase ast ck alt bicarb glucose creatinine


4. prempro as the patient was formerly taking .


1. levaquin 500 mg one po q day times seven days .


the patient was given a prescription for ten pills .


she was to continue on a brat diet over the weekend and two days after discharge she could advance to a low fat no dairy diet .


the patient is a 59 year-old female status post endoscopic retrograde cholangiopancreatography on the day of admission , which had been done to evaluate for possible bile leak after cholecystectomy was performed four days ago .


placement for a bile leak from the duct of luschka .


electrocardiogram showed normal sinus rhythm at 73 beats per minute .


3. hypokalemia .


the patient was to make an appointment with dr. nicholson within one to two months after discharge for removal of the stent .


5. bile leak .


her liver function tests and amylase and lipase were followed closely .


therefore she was made npo and given aggressive intravenous hydration .


her bicarb began to drop and she developed an anion gap acidosis .


the patient was in her usual state of health until four days prior to admission when she had a cholecystectomy .


on the day of discharge the patient was tolerating a brat diet without significant abdominal


pain .


her postop course was uneventful until one day prior to admission when she developed abdominal pain .


2. protonix 40 mg po q day .


on the day of admission she returned to the outside hospital emergency room where an abdominal ct was performed , which showed " thickened stomach and free air ."


the patient was aggressively hydrated given that she was npo .


3. percocet one to two tablets po q 4 to 6 hours prn .


there were post laparoscopic incisions without erythema with steri-strips in place .


she was followed closely with serial abdominal examinations .


she was started on ampicillin , gentamycin and flagyl .


there were no rashes .


the patient was admitted originally for airway monitoring status post endoscopic retrograde


white blood cell count 9.0 , hematocrit 39.3 , platelets 296 , neutrophil count 82 , lymphocytes 14 , 4 monocytes , troponin was less then 0.3 .

lymphocytes
monocytes
troponin
neutrophil count
hematocrit
platelets
white blood cell count


cholangiopancreatography with adverse reaction to fentanyl and tongue injury .


there was no rebound or guarding .


abdominal ct showed inflammation in the right upper quadrant , small fluid in the circumferential thickening of the distal stomach .


however , her white blood cell count was never really elevated and she did not have a bandemia .


there was a tiny amount of free air .


her amylase and lipase on the day following the endoscopic retrograde cholangiopancreatography


amylase was 2304 with lipase being 7116 .


abdomen was soft , nontender , nondistended .


2. anemia .


an abdominal ct was obtained , which showed only mild pancreatitis .


1. post endoscopic retrograde cholangiopancreatography pancreatitis .


there were no intra-abdominal fluid collections , which required any drainage .


on the third hospital day the patient 's pain was improving and the rebound was decreasing .


5. trazodone at bedtime .


the patient received ampicillin , gentamycin and flagyl empirically as well as narcan to reverse fentanyl .

fentanyl flagyl narcan gentamycin ampicillin


after her endoscopic retrograde cholangiopancreatography the patient developed " jaw clenching , biting tongue , rigidity and cold / chills ."

rigidity
cold / chills
biting tongue
jaw clenching


were elevated .


in general , the patient was groggy status post anesthesia , shivering , but awake .


no murmurs , rubs or gallops .


she had no further rebound .


this was most likely secondary to ketoacidosis as she had no dextrose in her intravenous fluids .


sating 98% on 3 liters .


she required periodic repletion of her potassium .


blood pressure 162/76 .


she had no temperature spikes in greater then 24 hours at the time of discharge .


the patient 's hematocrit was 34.8 at the time of admission .


4. anion gap acidosis .


it decreased to 30 in the setting of aggressive hydration .


no known drug allergies at the time of admission , however , it is assumed that her rigidity and jaw clenching was secondary to fentanyl .

her rigidity
jaw clenching
known drug allergies


her enzymes continued to trend down .


this was added on the evening prior to discharge and on the day of discharge her anion gap acidosis had resolved .


vital signs temperature 100.6 .


the patient was continued on ampicillin , gentamycin and flagyl , which had been started at the time of transfer to the cmed ccu .


3. urinary frequency secondary to interstitial cystitis .


1. prempro .


she received clear liquids in the evening and tolerated these well .


4. mitral valve prolapse .


the extremities were without edema .


respiratory rate 18 .


on the day of transfer to the general medical floor the patient had received clear liquids .


1. hiatal hernia .


because of the tongue injury and tachycardia as well as possible infection given her fevers or chills the gi service transferred the patient to the cmed ccu for close observation .

chills
tachycardia
infection
her fevers
the tongue injury


she had waxing and waning fevers .


5. tubal ligation many years ago .


on the second hospital day on the general medical floor the patient had marked rebound to palpation of her abdomen .


2. cmed ccu drops .


heart rate 105 .


her amylase and lipase were trending down , however .


2. status post cholecystectomy four days prior to admission .


there was a question of a small ulcer .


there were no st or t wave changes .


dorsalis pedis pulses were intact bilaterally .


in summary the patient is a 59 year-old female who was admitted to quincy medical center for an endoscopic retrograde cholangiopancreatography for possible stent placement for a bile leak secondary to cholecystectomy performed four days prior to admission .


a stent was placed successfully .


she had a successful endoscopic retrograde cholangiopancreatography , which showed a bile leak at the duct of luschka .


heent showed tongue with laceration on the right edge .


she then suffered rigidity with jaw clenching and tongue biting secondary to fentanyl administration and was transferred to the cmed ccu for close observation .


lungs were clear to auscultation bilaterally .


she was sent to new england sinai hospital & rehab center for an endoscopic retrograde cholangiopancreatography and possible stent placement .


as stated the patient was status post endoscopic retrograde cholangiopancreatography with stent


2. hepatic candidiasis .


1. burkitt's lymphoma .


the patient went for a repeat mri which showed no change in the previously noted enumerable hepatic cyst in her liver .


she is also started on marinol 2.5 mg p.o. b.i.d. and encouraged p.o. intake .


the patient was continued on tpn over the past couple days .


1. liver lesions :


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


a hepatology consult was obtained who felt that the most likely etiology of these cysts were from hepatic candidiasis , although one could not rule out lymphoma involving from burkitt's .

lymphoma
hepatic candidiasis
these cysts
burkitt's


3. atarax 25 mg iv / p.o. q. 4-6 h. prn for itching .


this regimen , that being ambisome , was recommended by the infectious disease physicians , who felt that ambisome was a better drug of choice as compared to fluconazole .


6. nystatin 06-18 ml swish and swallow q.6. prn .


7. peridex 15 ml swish and swallow prn .


5. protonix 40 mg p.o. / iv q.d.


1. ambisome 300 mg iv q.d.


her white count remained elevated despite discontinuing her g-csf .


3. on the morning of 12-01 , the patient had some transient episodes of hypotension with sbp s in the 70 s.


the patient 's platelets , white count , and hematocrit have all been stable .

white count
hematocrit
the patient 's platelets


her captopril was discontinued , and she was given two iv fluid boluses with appropriate response .


however , the patient is not febrile and her white count should be continued to be watched .


2. marinol 2.5 mg p.o. b.i.d. before breakfast and dinner .


again , this was a 47-year-old female admitted with berkitt's lymphoma .


her blood pressures and all of her vital signs are stable .


she will be discharged on ambisome 300 mg iv q.d. for treatment of her hepatic candidiasis .


guarded , but stable .


mr. eugene is a 67 year old male with a remote history of chronic pancreatitis due to alcohol abuse 30 years ago , who is transferred now from rehab hospital of the cape & islands hospital for an ercp and work-up for a cystic lesion at the head of his pancreas on ct scan shown at the outside hospital .


3. prilosec 20 mg p.o. q. day .


that evening , the patient again developed abdominal pain " like his pancreatitis " with nausea and vomiting , for which he was admitted to the rehab hospital of the cape & islands hospital .

abdominal pain
his pancreatitis
nausea
vomiting


2. nph 10 units subcutaneously every morning and 8 units subcutaneously every evening .


during this admission , two ct scans had shown a question of an enlargement of the head of his pancreas


abdominal examination revealed an abdomen that is nondistended , nontender .


3. flomax 0.4 mg p.o. q. day .


pulmonary examination revealed lungs clear to auscultation bilaterally .


1. augmentin 500 mg p.o. three times a day times ten days .


there was no rebound ; no munos sign .


4. prilosec 30 mg p.o. q. day .


2. right rotator cuff injury .


the patient is allergic to ciprofloxacin , morphine sulfate and droperidol .

morphine sulfate
ciprofloxacin
droperidol


it appears from the discharge summary that the patient was placed on unasyn 3 grams intravenously every six hours after his ercp .


3. gastroesophageal reflux disease with esophageal dilatation for stricture .

gastroesophageal reflux disease
stricture


the patient subsequently underwent a ct scan angiogram with pancreas protocol to assess the pseudocyst versus enlarged pancreas head .


1. type 2 diabetes mellitus .


infectious disease department as well as cardiology had recommended a formal 14 - day course of intravenous antibiotics to treat a documented alpha streptococcal septicemia from outside hospital blood cultures .


he had three days of antibiotics remaining at the time of discharge .


4. humalog and regular insulin subcutaneously .


2. alpha streptococcus septicemia .


1. pancreatitis status post endoscopic retrogram cholangiopancreatography and sphincterotomy .


4. regular insulin 15 units q. a.m. and 14 units q. p.m.


1. unasyn 3 grams intravenous every six hours .


1. prilosec 20 mg p.o. q. day .


the patient was alert , awake and oriented , pleasant , and in no acute distress .


2. flomax 4 mg p.o. q. day .


on admission showed a temperature of 97.1 f. ; heart rate of 65 ; blood pressure of 146/74 ; respiratory rate of 20 ; oxygen saturation 98% on three liters and 95% on room air .

oxygen saturation
a temperature
heart rate
blood pressure
respiratory rate


his liver span was 8 cm .


he was to return to the hospital with any signs of shaking chills or fever .


3. humalog 75/25 , subcutaneously .


cardiovascular system revealed normal s1 and s2 , no murmurs or gallops and regular rate and rhythm .


6. tylenol .


he had no icterus .


2. flomax 0.4 mg p.o. q. day .


extremities reveal no edema , no swelling .


this was sensitive to clindamycin , erythromycin , penicillin s and vancomycin .

vancomycin
penicillin s
erythromycin
clindamycin


there was no formal strength test done .


liver function tests revealed an alt of 31 , ast of 36 , alkaline phosphatase of 509 .

ast
liver function tests
an alt
alkaline phosphatase


the patient 's blood cultures at outside hospital grew out streptococcus sanguis-gordonii on 01-18 .


total bilirubin was 0.8 .


he was therefore transferred to saints medical center for endoscopic retrogram cholangiopancreatography .


chemistry on admission showed a sodium of 141 , potassium of 4.3 , chloride of 107 , bicarbonate of 25 , bun of 4 , creatinine of 0.6 and a sugar of 177 .

a sugar
bicarbonate
chloride
potassium
a sodium
creatinine
bun


the patient had an attempted ercp on 01-18 , which was unsuccessful due to a long nipple like papilla .


the patient presented initially to rehab hospital of the cape & islands hospital at the end of december for abdominal pain , and was found to have pancreatitis .


an ultrasound showed normal gallbladder with no wall thickening but a dilated common bile duct of 8 mm measured on ct scan .

a dilated common bile duct
wall thickening


he received an mrcp which was negative for evidence of stones .


neurologic examination revealed an alert and oriented individual .


the patient lives with his disabled wife who has a psychiatric condition .


during his admission to rehab hospital of the cape & islands hospital , the patient had dropped his hematocrit to the 30 s with recorded melena .


a chest x-ray was unremarkable .


his electrocardiogram showed a normal sinus rhythm .


a hida scan showed no flow , question of pancreatitis versus common bile duct obstruction .

pancreatitis
no flow
common bile duct obstruction


his complete blood count showed 11% bandemia with a total white count of 10 .

a total white count
his complete blood count


urinalysis revealed trace glucose , no ketones , no red cells , no white cells and less than one epithelial cells .

white cells
trace glucose
ketones
red cells


the patient underwent a percutaneous sphincterotomy extended to a full sphincterectomy .

a percutaneous sphincterotomy
a full sphincterectomy


he also had successful extraction of stone fragments .


the patient tolerated this procedure well and had no complications .


the results of this study indicated that this structure at the head of his pancreas is most likely a forming pseudocyst ; however , the suspicion of malignancy is still possible and the patient underwent an ultrasound guided biopsy of this mass on 2011-01-20 .

malignancy
this mass
a forming pseudocyst


studies revealed a hematocrit of 32.6 , white count of 6.0 .


his platelet count was 267 .


his alkaline phosphatase and all the other abnormal liver function tests were resolving .


his mcv was 88 , red cell distribution was 13.4 .


he had no pain and did not require any pain medications .


he was also found to have dilated pancreatic ducts with calcifications consistent with chronic pancreatitis .

chronic pancreatitis
dilated pancreatic ducts
calcifications


cytology was obtained .


he was tolerating food very well and was afebrile throughout admission .


prior to this result , the patient had already been on ampicillin , sulbactam and gentamycin .


6. status post tonsillectomy as a child .


the cytology for this biopsy is still pending .


head , eyes , ears , nose and throat examination revealed mucous membranes that were moist .


the patient recovered well status post these two procedures .


5. regular insulin sliding scale .


on this examination , the patient was found to have mild biliary stricture most likely secondary to chronic pancreatitis .

mild biliary stricture
chronic pancreatitis


his blood cultures were drawn and pending .


the patient was taken down to the endoscopic retrogram cholangiopancreatogram upon admission .


albumin was 2.6 .


versus early pseudocyst .


there was focal mitral valve prolapse noted without pathologic mitral regurgitation .

focal mitral valve prolapse
pathologic mitral regurgitation


the patient , on admission , was placed on ampicillin , gentamycin and flagyl .


with repeated blood cultures that were negative , the patient was reduced to single mckenzie of intravenous ampicillin .


a complex plaque was found in the aortic arch in the descending thoracic aorta , although this plaque is non-mobile .


the patient was thought to have normal dental hygiene and low suspicion for a source of his alpha septicemia from his mouth .


there were no other abnormalities noted on this study .


the patient was noted to have trace aortic regurgitation .


a panorex x-ray of his two teeth were obtained and a dental consultation was done .


he had no complications and no subsequently pancreatitis .


it was discussed with the patient to send him out on augmentin 500 mg three times a day for ten more days .


for this documented septicemia , this patient went for a endocarditis work-up .


the patient 's insurance company , however , would not pay for home antibiotics .


after much discussion with the patient , the patient was informed of the risks of not finishing a 14 day course of intravenous antibiotics and chose to go home .


he was to follow-up with his primary care physician within two to three days for repeat laboratory studies and blood cultures .

repeat laboratory studies
blood cultures


the patient appeared to have been covered by ampicillin , gentamycin and then unasyn in the outside hospital .


4. recent pancreatitis ; prior history for recurrent pancreatitis 30 years ago from alcohol .

recurrent pancreatitis
recent pancreatitis


upon obtaining more information from rehab hospital of the cape & islands hospital , it appears that the patient had two out of four bottles growing out streptococcus sanguis in the outside hospital .


he had a transthoracic echocardiogram which revealed no vegetations .


5. history of streptococcemia in the year 2008 ; source was unclear but presumed to be urinary .


transfer from rehab hospital of the cape & islands hospital for an endoscopic retrogram cholangiopancreatography .


on this echocardiogram , he was found to have mildly dilated left atrium , mild symmetric left ventricular hypertrophy , and a normal ejection fraction of greater than 55% .


on an office visit on 01-14 , the patient was found to have significantly elevated alkaline phosphatase .


with regards to the patient 's documented strep septicemia in the outside hospital , the infectious disease team was formally consulted .


on this echocardiogram , he was again noted to not have any evidence for valvular vegetations .


the patient then underwent a transesophageal echocardiogram on 01-24 .


the patient became hypotensive into the 70 s without any symptoms .


hypotension - on the night of 10-16 , the patient was diuresed with 20 mg of intravenous lasix .


red blood cells with a good response up to 30 .


she continues on her prednisone taper for her asthma and this is day # 14 of antibiotics .


respiratory distress - on 10-12 , the patient was transferred to medicine intensive care unit secondary to respiratory distress .

respiratory distress
respiratory distress


in the medicine intensive care unit , the patient was initially placed on high-flow 60% oxygen face mask and they diuresed approximately 5 liters off into the intravenous lasix .

high-flow 60% oxygen face mask
the intravenous lasix


anemia - the patient 's hematocrit dropped in the intensive care unit to the mid 20s and she received one unit of packed


no further episodes of hypotension were noted .


the patient was given 250 cc of normal saline and her blood pressure responded coming back up to the high 90 s.


since then the patient 's oxygenation has been improving and today , 10-17 , she is requiring .5 liters of keep her saturations above 94 .


the patient continues to be diuresed with approximately 20 mg of lasix a day and she has had good urine output .


recent chest x-ray shows resolving right lower lobe pneumonia .


her oxygen saturations were greater than 94% at the time .


7. clonidine 0.2 mg tablet sig : one ( 1 ) tablet po tid ( 3 times a day ).


carduac enzymes mildly elevated , felt 02-08 demand ischemia in setting of hypertensive urgency , ck and mb trended mcewen at time of admission to medical floor .

demand ischemia
hypertensive urgency
carduac enzymes mildly elevated


plan is for surveillance cultures to be drawn at dialysis .


upon presentation it was unclear when last time was that patient took meds , but hypertension likely d/t inability to take meds in setting of n/v .


general : sleepy , arouses to voice but limited participation with physical exam


pt will compelete a 2 week course of vancomycin at hemodialysis , which has been arranged by renal service .


6. clonidine 0.3 mg / 24 hr patch weekly sig : one ( 1 ) patch weekly transdermal q wed ( every wednesday ).


pt with surveillance cultures and port tip cultures showing ngtd on 01-24 , he will have futher surveillance cultures drawn at hemodialysis and followed by his nephrologist .

port tip cultures
futher surveillance cultures
surveillance cultures


his father recently died of esrd and diabetes .


if you have recurrent fevers , chills , naseau , vomitting , chest pain , shortness of breath , or other worrisome symptoms , please contact your primary care physician or the emergency department .

other worrisome symptoms
naseau
shortness of breath
vomitting
recurrent fevers
chills
chest pain


pt discharged home on 01-24 with instructions to complete 2 week course of vancomycin at hemodialysis for his port line infection .


# hypertensive urgency :


pt admitted to medical floor in hemodynamically stable condition without specific complaints .


you were started on a 2 week course of vancomycin to be given at hemodialysis for your line infection .


if negative , pt is scheduled for presumptively replacement of port on 2019-02-11 with interventional radiology ( dr. arevalo ).

interventional radiology
presumptively replacement of port


6. hx of foot ulcer


no signs of infection presently , and tolerating dialysis without difficulty .


skin : no rashes


you will have your port replaced after 2 weeks of antibiotics if your blood cultures remain negative .


he has two sisters , one with diabetes , and six brothers , one with diabetes .


heent : perrl , left pupil smaller than right , pt will not participate in eomi , sclera anicteric , mm dry , no op lesions

anicteric
left pupil smaller than right
mm dry
op lesions


pt with two episodes of hypoglycemia ( fsbs 22 and 27 ), etiology unclear , pt followed by strickland , who recommend no changes to current insulin regimen .


an appointment was made with interventional radiology on 2019-02-11 to replace his port , under the assumption that his surveillance cultures from dialysis remain negative .


# dmi : pt on sliding scale as inpatient and taking nph 2 units bid at home .


upon transfer to the cmed ccu the patient appears somewhat uncomfortable , reporting nausea and abdominal pain , but when questioned he was unable / unwilling to participate in hpi or exam d/t sleepiness .

somewhat uncomfortable
nausea
abdominal pain
sleepiness


5. dilaudid 4 mg tablet sig : one ( 1 ) tablet po q3-4hr prn .


vitals : 97.4 , 164/90 , 102 , 10 , 97% 4l


# esrd : etiology likely 02-08 dm and htn , pt tolerating hd well , and underwent dialysis without difficulty on 01-24 .


cardiac and infectious sources of hypotension were considered , but cardiac enzymes were not changed from prior studies and he had no localizing signs of infection ; blood cultures were sent and a ultrasound of the l arm avf ordered to rule out abscess at the site .

abscess at the site
localizing signs of infection
hypotension

blood cultures
cardiac enzymes
a ultrasound


etiology felt most likely demand ischemia in setting of original hypertensive urgency with persistent elevation of trop 02-08 esrd .

esrd
demand ischemia
original hypertensive urgency
persistent elevation of trop


pt continued on home regimen of calcium acetate 667 mg , 3 capsules tid .


labetalol was stopped and he received a 500 cc fluid bolus and his blood pressure rose to sbp 90 s.


pt was subtherapeuticon inr on admission , thus treated with heparin gtt .


he eloped prior to formal discharge when his fs was found to be critically high - recommended to patient that he stay for repeat , but left ama without signing any forms .


he will have levels drawn at dialysis and be dosed with vancomycin as appropriate .


also had labile blood sugars with repeated episodes of hypoglycemia , and strickland recommended sugars in the range of 150-200 .


in addition pt will be given vancomycin at dialysis x 2 week course ( last day 2019-02-05 ) given his port line infection .


he denied cp , sob , ha , vision changes , neck stiffness , dysuria , or other symptoms .

other symptoms
sob
cp
ha
neck stiffness
dysuria
vision changes


ext : no c/c/e , left arm with fistula with good thrill


# av fistula : pt with h/o numerous clots in av fistula .


pt discharged with instructions to continue coumadin 1.5 mg po q daily with goal inr 02-09 .


pt was continued on aspirin , metoprolol , nifedipine .


pt will be discharged home with plan to continue current dialysis schedule ( tue / th / sat ).


coumadin held on 01-22 for port removal , and restarted on 01-24 .


in the cmed ccu he became hypotensive to sbp 80 s.


calcium acetate 1340 mg tid with meals


troponins rose at admission , however ck and mb trending mcewen wat time of admission to medical service .


port was felt most likely source , and pt has had at least 2 sets of + blood cultures since it was placed .


metoprolol tartrate 75 mg po tid


anzemet 12.5 iv prn


# n/v/ abdominal pain : pt with multiple admissions with similar complaints , etiology 02-08 gastroparesis , improves considerably with ativan , dilaudid , reglan , pt was tolerating po meds / diet at time of admission to medical service and was restarted on oral reglan .

abdominal pain
gastroparesis
similar complaints
n/v/

reglan
po meds
oral reglan
dilaudid
ativan


metoclopramide 10 mg po q6


history is difficult to obtain from patient d/t somnolence and lack of desire to participate in interview , but per frank note he was diaphoretic and ' writing in pain ', vomiting clear substance .

pain
diaphoretic
somnolence
lack of desire


insulin nph 2 units subcutaneous twice a day .


he was restarted on his home regimen of antihypertensives without difficulty ( metoprolol 75 tid , clonidine patch and oral , nifedipine 30 sr q daily ).

antihypertensives
clonidine patch and oral
nifedipine
metoprolol


this is a 37 y/o male patient with pmh type i dm , htn , gastroparesis , esrd on hd ( last in 12/26 per patient ) who presents to cmed ccu with hypertensive urgency unable from the larry .

esrd
gastroparesis
type i dm
htn
hypertensive urgency


clonidine 0.3 mg / 24 hr patch weekly transdermal qthur


his sbp s ranged 140 s- 170 s .


# cad - pt denied cp / sob throughout hospitalization .


clonidine 0.2 mg po tid


prochlorperazine 10 mg q 6 h


prochlorperazine 10 mg iv q6h prn


nausea and vomiting


will discharge pt with instructions to continue nph 2 units bid as frederick tracey recs .


pt 's hypertensive urgency was resolved upon admission to the medical floor .


ativan 1 mg po q6h prn


dilaudid 4mg po q3-4h prn


no evidence of active end organ damage .


protonix 40 qd


01-23 picc placement .


pt was treated with labetalol gtt in cmed ccu which was weaned off on 01-20 .


also contribution of autonomic dysfunction .


1. metoclopramide 10 mg tablet sig : one ( 1 ) tablet po q6h ( every 6 hours ).


2. metoprolol tartrate 25 mg tablet sig : three ( 3 ) tablet po tid ( 3 times a day ).


coumadin 1.5 mg po qhs


abd : soft , nd , nontender , + bs , no guarding , no rebound , multiple well healed scars

multiple well healed scars
nd
nontender
guarding
rebound


nifedipine 30 sr mg po qd


bisacodyl prn


he was given ativan a total of 4 mg of ativan , 6 mg of dilaudid , labetolol 20 mg iv x 1 and hydralazine 10 mg iv x 1 without good response ( 200/99 ).

dilaudid ativan ativan hydralazine labetolol


01-24 picc removal .


tte was obtained which was not concerning for endocarditis .


pt without stigmata of sbe .


01-23 port line removal .


he recieved 2l ns and was started on labetolol gtt and bp decreased to 161/79 .


id consult obtained which recommended removal of port , which was taken out on 01-23 .


7. h/o clot in av graft x2 ( march and 2018-07-07 )


a picc was breifly placed , however removed as it is unclear if pt can reliably flush this .


at that time bp was attributed to abdominal pain and inability to take po meds d/t nausea / vomiting .


tranferred to cmed ccu for further management while on labetolol gtt .


patient recorded as having no known allergies to drugs


# bacteremia :


pt with 2/4 bottles coag neg staph on 01-19 and again on 01-20 .


the patient early this morning to the ruthie with his usual nausea , vomiting , abdominal pain and was found to be hypertensive to 256/110 , hr 102 , t 99.2 , rr 22 , 92% ra .

hypertensive
abdominal pain
vomiting
his usual nausea


his blood sugar at 10 pm was low at 22 and he was disoriented , which resolved with two glasses of juice ; he did not receive his standing dose of nph that evening .


he was to be called out to the medical floor on 2019-01-20 but became somnolent after receiving pain and anti-nausea meds , so he stayed in the icu for closer monitoring of respiratory status , which spontaneously improved .


blood cultures returned positive with gpc in pairs and clusters , so a tte and surveillance cultures were ordered and vancomycin was started .

surveillance cultures
blood cultures
a tte


over night , his blood pressure trended up to 130 s systolic .


port will be replaced on 2019-02-11 per ir ( dr. welsh placed last port , then removed it on 01-23 ), ordered placed in omr .


please follow-up with your dialysis physician regarding replacing your port .


he was restarted on his home blood pressure regimen .


he received a partial hd session , limited by hypotension .


3. severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency , gastroparesis , and orthostatic hypotension .

gastroparesis
hypertensive emergency
orthostatic hypotension
severe autonomic dysfunction


diabetic gastropathy causing inability to toleral oral antihypertensive medication prompting repeated donald presentation for hypertensive urgency .


1. dm type i


please continue to take all of your medications as prescribed .


5. cad with 1-vessel disease ( 50% stenosis d1 in 2014-06-07 ), normal stress


bacteremia 02-08 port line infection


diabetic gastropathy


hypertensive urgency


2. esrd on hemodialysis started 2017-01-07 on tu , th , sat


13. aspirin 81 mg tablet sig : one ( 1 ) tablet po once a day .


14. humalog 100 unit / ml solution sig : use as directed subcutaneous four times a day : please use attached sliding scale .


15. insulin nph human recomb 100 unit / ml suspension sig : 2 units subcutaneous twice a day .


neck : supple , no jvd


cv : rrr , nl s1 , s2 , 2/6 systolic murmur at lusb


11. bisacodyl 5 mg tablet sig : one ( 1 ) tablet po once a day as needed for constipation .


12. vancomycin in dextrose 1 g / 200 ml piggyback sig : one ( 1 ) intravenous qhd ( each hemodialysis ): 2 week course to be given at dialysis , last day 2019-02-05 .


chest : hd line in place without erythema


his mother is in her 50 s and has hypertension .


9. nifedipine 30 mg tablet sustained release sig : one ( 1 ) tablet sustained release po daily ( daily ).


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


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


4. ativan 1 mg tablet sig : one ( 1 ) tablet po q6h prn .


4. history of esophageal erosion , mw tear


8. warfarin 1 mg tablet sig : 1.5 tablets po daily ( daily ).


the patient overall continued to improve , but remained physically decompensated and the patient was transferred to waltham/weston hospital rehabilitation hospital for intensive physical therapy .


with regard to the patient 's chronic obstructive pulmonary disease , the patient 's respiratory status improved throughout the remainder of her hospital course .


this was treated with wound care using eucerin cream and also patient was treated with lidocaine jelly for pain control .

eucerin cream
lidocaine jelly
pain control
wound care


the patient had no shortness of breath or cough on discharge .


discharge medications are the same with the addition of viscous lidocaine jelly to be applied to buttock prn and viscous lidocaine swish and swallow tid prn before meals .

viscous lidocaine jelly
discharge medications
viscous lidocaine swish and swallow


the patient was oxygenating well on her home o2 dose of 2 liters per minute .


the patient had stage 1 sacral decubitus on her buttocks .


the patient was seen by the wound care nurse and the decubitus ulcer was felt to be mild , but was causing the patient a lot of discomfort and the wound care nurse ivy rose lidocaine jelly .


showed normal sinus rhythm at 107 beats per minute with left axis deviation and poor r-wave progression .

poor r-wave progression
left axis deviation


however , no acute changes were apparent .


denies fever or chills .


it was believed that a troponin on admission in addition to the wall motion abnormalities she underwent a non-q wave myocardial infarction prior to resulted in her current cardiac failure .

her current cardiac failure
the wall motion abnormalities
a non-q wave myocardial infarction


she also noted increased dyspnea on exertion .


bowel sounds positive , soft , non-tender , non-distended .


3. isosorbide mononitrate 30 q. day .


electrocardiogram :


chest x-ray showed patient was in congestive heart failure .


1+ lower extremity edema .


this is an 86-year-old female with a past medical history of diabetes and hypertension who presented to the emergency department with a two day history of shortness of breath and easy fatigability .

easy fatigability
shortness of breath
diabetes
hypertension


a cardiac catheterization was deferred until the renal issue could be resolved .


included normal cbc , bun 47 , creatinine 2.4 up from baseline of about 1.5 .


in general , patient in no acute distress .


also of note was the distal lateral wall hypokinesis .


echocardiogram was obtained which showed moderately depressed left ventricular systolic function as well as hypokinesis of the lower half of septum and apex .


diuresis was halted and without improvement in creatinine .


on admission , blood pressure 151/61 , heart rate 75 , sao2 93% on room air .


jugular venous pressure notable at the mid neck upright about 80 degree angles .


crackles bilaterally one-third to one-half the way up .


the patient was admitted to the cardiac medicine service and treated for presumed diastolic and systolic dysfunction .


she was started on _________ with excellent diuresis , however , her renal functioning worsening .


cardiovascular regular rate and rhythm with a 1-2/6 holosystolic murmur .


it showed a right kidney size of 6.3 cm and a left kidney size of 8.4 cm .


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


she has not required hemodialysis at this time .


2. norvasc 10 mg p.o. q. day .


no coronary artery disease .


throughout hospital course patient 's troponin trended down to less than 0.3 .


positive for diabetes .


however , her creatinine continued to increase .


there was also moderate to severe focal stenosis of the left renal artery approximately 1.3 cm from its origin .


given her hypertension which was very difficult to control , it was felt that she had renal artery stenosis and thus she underwent mra of the kidney which showed severe right renal artery stenosis at its origin .


she was continued with aggressive diuresis .


on 05-25 she underwent catheterization and subsequent stenting of the left renal artery .


the wall motion abnormalities were noted to be new .


no known drug allergies .


she denies chest pain , orthopnea , paroxysmal nocturnal dyspnea .

chest pain
orthopnea
paroxysmal nocturnal dyspnea


7. ___________ dinitrate 20 mg p.o. t.i.d.


6. carvedilol 3.125 p.o. b.i.d.


due to dye load required to assess the coronary disease were not visualized .


9. calcium acetate tums one p.o. t.i.d. with meals .


4. terazosin 1 mg p.o. q. day .


8. erythropoietin 10,000 units two times a week tuesday and saturday .


4. protonix 20 mg p.o. q. day .


3. atorvastatin 10 mg p.o. q. day .


she was transferred to the unit overnight to assess volume which was noted to be optimal .


a renal ultrasound was obtained .


5. multivitamin one p.o. q. day .


11. iron sulfate 325 mg p.o. q. day .


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


10. tylenol 325 mg p.o. q. 4-6 h. p.r.n.


14. plavix 75 mg p.o. q. day times 30 days .


of note , she has had recent medication changes which included discontinuing diovan and starting terazosin .

terazosin
diovan
recent medication changes


13. hydralazine 10 mg p.o. q. 6h.


however , her creatinine has worsened up to 4.2 .


however , her urine output has improved .


1. non-q wave myocardial infarction .


4. acute renal failure .


after the procedure the patient did well .


however , the patient has noted some abdominal pain , intermittent times a couple of days , none on the day of admission .


2. systolic and diastolic congestive heart failure .


3. bilateral renal artery stenosis status post stent left renal artery .


5. hypertension .


denied nausea , vomiting , diaphoresis , bowel movement changes .

nausea
bowel movement changes
diaphoresis
vomiting


troponin 4.7 , ck 101 , mb 3 .


2. norvasc 10 mg p.o. q. day .


3. osteoarthritis .


2. hypertension .


she has noted increased urinary frequency .


1. diabetes mellitus .


22 year old female transfer from outside hospital after a motor vehicle accident with diagnosed liver laceration by ct scan .


glucose - 74 urea n - 9 creat - 0.7 sodium - 139 potassium - 3.5 chloride - 106 total co2 - 23 anion gap - 14

glucose
sodium
creat
urea n
chloride
potassium
anion gap
total co2


glucose - 75 urea n - 10 creat - 0.6 sodium - 137 potassium - 3.7 chloride - 103 total co2 - 23 anion gap - 15

chloride
sodium
potassium
total co2
glucose
creat
anion gap
urea n


abdominal pain predominally on the right upper quadrant , no signs of peritoneal irritation .


alt(sgpt) - 318 * ast(sgot) - 307 * alk phos - 61 tot bili - 0.9


1. docusate sodium 100 mg capsule sig : one ( 1 ) capsule po bid ( 2 times a day ) for 4 days .


left forarm and right knee abrasions .


call trauma clinic to coordinate the study , result and appointment dates (( 289 ) 411-5387 ).


- if any abdominal pain , fever or dizziness , go to the emergency room


the liver enzimes come down , no signs of biliary stasis .


calcium - 8.2 * phosphate - 3.1 magnesium - 2.2


- follow up with trauma surgery clinic with the result from the ct scan abdomen


- trauma surgery clinic in four weeks with ct abdomen results .


- call for appointment to ( 289 ) 411-5387 for the trauma clinic and abdominal ct scan of the abdomen in 4 weeks


2. hydromorphone 2 mg tablet sig : one ( 1 ) tablet po q2h ( every 2 hours ) as needed for pain for 4 days .


patient was admited , pain was managed with a pca and later with po medication .


pt - 11.6 ptt - 26.0 inr(pt) - 0.9


the liver laceration was stable , no sign of rupture or further complication , did not required surgical managment .

the liver laceration
further complication
rupture


chest clear to auscultation bilateral , s1 s2 normal and with no murmors .


wbc - 8.3 rbc - 3.64 * hgb - 12.6 hct - 36.1 mcv - 99 * mch - 34.7 * mchc - 35.0 rdw - 12.4


alt(sgpt) - 241 * ast(sgot) - 207 * alk phos - 51 tot bili - 0.8


- analgesic ( percocet ) as needed


neck with cervical collar .


cath lab at the pinewood , norfolk that evening where a stent procedure to the rca was complicated by guidewire entrapment inside of a stent requiring ct surgery to do a thoracotomy with bypass and excision of the wire .

ct surgery
bypass
a stent
a stent procedure to the rca
excision of the wire
a thoracotomy


the patient was taken emergently to the operating room on 2009-05-02 for his cabg , right coronary endarterectomy , removal of rca stents and retrieval of the aortic guidewire .

removal of rca stents
right coronary endarterectomy
retrieval of the aortic guidewire
his cabg


6. percocet one to two tablets q four h prn for pain .


the case was complicated by an episode of coffee ground emesis and a bleed from femoral access site prior to ct surgery .

coffee ground emesis
a bleed from femoral access site


5. colace 100 milligrams po bid .


symptoms resolved spontaneously .


postoperatively he did well and was transferred to the cardiac surgery intensive care unit where he was on pressor support of neo-synephrine and he was extubated .


the patient slowly weaned off neo-synephrine as tolerated .


8. aspirin 325 milligrams po q day .


he is a 39 year-old gentleman with hyperlipidemia and smoking who presented with acute onset of chest pain since five in the morning with radiation to the left arm and nausea .


gastroenterology was consulted and they recommended protonix and felt it was due to peptic ulcer disease .


his electrolytes were repleted and the patient was discharged home on 2009-05-06 after tolerating a level v .


3. fatty liver resolved .


7. plavix 75 milligrams po q day times three months .


his chest tube had been discontinued .


relatively unknown other than lipitor .


upon arrival to the floor the patient 's wires were discontinued on 2009-05-05 and his foley catheter was discontinued .


allergies : he had no known drug allergies .


9. lasix 20 milligrams po times 30 days .


1. lopressor 25 milligrams po bid .


family history : not significant for coronary artery disease .


10. kcl 20 milliequivalents po q d times three days .


medications : his prescriptions shall include


1. hepatitis b .


2. lipitor 20 milligrams po q hs .


the patient was diagnosed as having an acute myocardial infarction .


2. hypercholesterolemia .


4. protonix 40 milligrams po q day .


3. niferex 150 milligrams caplet one cap per day .


his intravenous fluids were discontinued at this time .


his pain was well controlled with oral medication at this time .