she had a workup by her neurologist and an mri revealed a c5-6 disc herniation with cord compression and a t2 signal change at that level .

cord compression
a c5-6 disc herniation
a t2 signal change


3. percocet , 5/325 , 1-2 tabs po q4-6h prn pain .


microscopic anterior cervical diskectomy at c5-6 and fusion .


significant for hypertension , hyperlipidemia .


her pain was under good control with po pain medications and she was deemed suitable for discharge .


the patient was asked to call dr. miezetri gach 's office for a follow-up appointment and wound check .


lipitor , flexeril , hydrochlorothiazide and norvasc .

flexeril lipitor norvasc hydrochlorothiazide


she is asked to call with any fevers , chills , increasing weakness or numbness or any bowel and bladder disruption .

chills
fevers
numbness
bowel and bladder disruption
increasing weakness


she had hyperreflexia in both the bilateral upper and lower extremities .


1. colace , 100 mg po bid .


she had a postoperative ct scan that revealed partial decompression of the spinal canal and good placement of her hardware .


she had a hoffman 's sign greater on the right than the left and she had 10 beats of clonus in the right foot and 3-5 beats in the left foot .

10 beats of clonus
3-5 beats in the left foot


the patient is a 63-year-old female with a three-year history of bilateral hand numbness and occasional weakness .

bilateral hand numbness
occasional weakness


c5-6 disc herniation with cord compression and myelopathy .

c5-6 disc herniation
cord compression
myelopathy


within the past year , these symptoms have progressively gotten worse , to encompass also her feet .


5. hydrochlorothiazide , 25 mg po daily .


immediately postop , her exam only improved slightly in her hyperreflexia .


6. norvasc , 5 mg po daily .


she has no known drug allergy .


the patient tolerated a c5-6 acdf by dr. miezetri gach quite well .


4. lipitor , 10 mg po daily .


2. zantac , 150 mg po bid .


dilaudid 2mg po x 1 flexeril 10 mg x 1


take codeine prescribed by pcp with food and water to prevent nausea and constipation .


left shoulder / neck strain / sprain .


do not drive if taking flexeril and codeine .


l shoulder inj


the patient was given printed instructions for neck strains ( english ) .


flexeril 10mg tid


ivf , cbc ( hct 36 ) , normal chem 7 , negative cardiac enzymes , negative stool guaiac , normal cxr


near syncope , dehydration vs cardiogenic


the patient is to return to the ed for recurrent dizziness , chest pain , shortness of breath or weakness .

recurrent dizziness
chest pain
shortness of breath
weakness


dr. foutchner will arrange for an outpatient holter monitor .


the patient was given printed instructions for dizziness ( english ) .


near syncope standardized discharge instructions :


cv - ischemia asa , lisinopril pump no evidence of failure


75 y / o f with dm , copd on 2l nc and bipap at night p / w generalized weakness and fatigue , urinary incontinence and shaking as well as increased sputum production .

copd
fatigue
generalized weakness
increased sputum production
dm
shaking
urinary incontinence


nad , pleasant , speaking in complete sentences , poor air movement bilaterally , l > r , no wheezes or rales , rrr , distant , abd benign , no edema , alert and oriented times three , no focal deficits , conversant studies :

nad
wheezes
focal deficits
poor air movement bilaterally
edema
rales


flare - steroids , cont prednisone 60 , taper slowly as tolerated , duonebs , advair , singulair , spiriva , claritin azithromycin for atypical bronchitis to complete a 5 day course , keep o2 sat 90-94 , home nocturnal cpap not tolerated in house , does well on nc , appears ato be at baseline

nc
advair
duonebs
singulair
steroids
azithromycin
claritin
prednisone
spiriva
home nocturnal cpap


- ekg sinus 92 , no st changes


cr 0.8 , stress incontinence by symptoms with increased cough , no evidence of uti , cont to closely monitor

symptoms
uti
stress incontinence
increased cough


improving , but still poor air movement , diffusely wheezy on exam , at baseline 2l o2 requirement

diffusely wheezy
still poor air movement


acetylsalicylic acid 81 mg po daily albuterol nebulizer 2.5 mg neb q4h starting today ( 03/17 ) prn shortness of breath lisinopril 10 mg po daily niferex-150 150 mg po bid prednisone taper po give 50 mg q 24 h x 1 dose ( s ) , then give 40 mg q 24 h x 1 dose ( s ) , then give 30 mg q 24 h x 1 dose ( s ) , then give 20 mg q 24 h x 1 dose ( s ) , then give 10 mg q 24 h x 1 dose ( s ) , then starting today ( 03/17 ) claritin ( loratadine ) 10 mg po daily

acetylsalicylic acid
albuterol nebulizer
claritin ( loratadine )
lisinopril
prednisone taper po
niferex-150


walk with assist per pt eval


if bs is less than 125 , then give 0 units subcutaneously if bs is 125-150 , then give 2 units subcutaneously if bs is 151-200 , then give 3 units subcutaneously if bs is 201-250 , then give 4 units subcutaneously if bs is 251-300 , then give 6 units subcutaneously if bs is 301-350 , then give 8 units subcutaneously if bs is 351-400 , then give 10 units subcutaneously and call ho call ho if bs is greater than 400 protonix ( pantoprazole ) 40 mg po daily combivent ( ipratropium and albuterol sulfate ) 2 puff inh qid fosamax ( alendronate ) 70 mg po qweek


standing pre-meal novolog .


per daughter these symptoms are typical of copd flare .


give on an empty stomach ( give 1hr before or 2hr after food ) singulair ( montelukast ) 10 mg po bedtime advair diskus 500/50 ( fluticasone propionate/... ) 1 puff inh bid caltrate + d 1 tab po bid lantus ( insulin glargine ) 35 units sc qam duoneb ( albuterol and ipratropium nebulizer ) 3/0.5 mg neb q6h starting today ( 03/17 ) prn shortness of breath , wheezing novolog ( insulin aspart ) 4 units sc ac


novolog ( insulin aspart ) sliding scale ( subcutaneously ) sc ac


t97.5 , hr 117 , bp156/81 , rr28 , o2 sats 87% ra ; 95% 4l


take with 8 oz of plain water spiriva ( tiotropium ) 18


id - afebrile , no wbc , started on azithromycin for copd flare


75 y / o f with h / o copd c / b frequent exacerbations p / w typical flare symptoms .

typical flare symptoms
copd
frequent exacerbations


dispo - to rehab when resp status improved , pt consulted


responsible after study for causing admission ) copd flare


f / u with pcp and dr. pump as scheduled , return to ed with worsening sob or increased cough or sputum production

sputum production
increased cough
worsening sob


copd ( chronic obstructive pulmonary disease ) dm cervical djd ( ) iron deficiency anemia ( iron deficiency anemia ) cervical and lumbar djd ( 12 ) osa ( sleep apnea ) s / p tb treatment ( 5 )


heme - chronic fe deficiency anemia , cont iron


- cxr no focal consolidation or edema , old biapical scarring abg 7.34/79/74 u / a negative

focal consolidation
edema
old biapical scarring


rec'd duonebs , solumedrol 125


endo - dm on insulin with steroids


ppx - lovenox , ppi


gi - bowel regimen


weakness


copd flare


rhythm resp - copd


give in addition to standing pre-meal novolog when patient will eat and food is in the room .


dizziness


benign positional vertigo vs labyrinthitis


meclizine 25 mg po bid .


return to ed or call pcp if symptoms worsen or if fever with headache .


the patient was given printed instructions for dizziness ( english ) .


head ct negative .


return immediately for worsening signs of infection ( increased swelling , pain , redness ) or for any neurologic changes ( blurry or double vision , headaches , trouble walking , etc ) .

blurry or double vision
any neurologic changes
headaches
trouble walking
increased swelling
pain
infection
redness


l upper lip / l nostril abscess


5 cc of purulent material drained by needle aspiration


swollen painful l side fc


augmentin 875 mg twice a day for 10 days .


the neuro-oncologist felt that because of the tremendous tumor burden that was likely causing his symptoms the patient will require open debulking as well as obtaining issue for a pathologic diagnosis .

his symptoms
the tremendous tumor burden


chest xray reveals no consolidation or signs of edema .


hypertension , cva 2001 , 2002 diabetes , laryngeal cancer , right cea , prostatectomy for bph , total knee replacement , status post appendectomy .

laryngeal cancer
bph
hypertension
diabetes
cva

appendectomy
total knee replacement
prostatectomy
right cea


no other masses or thyromegaly noted .


nkda .


the patient has an intention tremor with the left hand .


the patient can have voiding trials at rehab and he is being maintained on flomax .


the patient was taken off fluid restriction .


the patient is status post radiation therapy and resection and reconstruction for his laryngeal cancer .

radiation therapy
resection
reconstruction


over the next several days his sodium levels were followed and by 5/12/05 his plasma sodium was back to 136 .


afebrile , vital signs stable but notable for a blood pressure of 164/80 .


positive weakness , otherwise negative .


the patient was admitted to the neurologic service for workup of his tumor .


a postoperative mri was obtained which revealed no remarkable findings but only post surgical changes .

post surgical changes
remarkable findings


he reported that he began with difficulty buttoning his shirt for many years since after a stroke but now reports that on occasion she would ask him why he was doing certain things and he could not give a concrete example .


no hepato or splenomegaly .


no cervical , para-auricular or clavicular lymphadenopathy .


the patient is asked to see a physician immediately or go to the nearest emergency room if any bleeding , wound infection , fever greater than 100.8 , intractable nausea and vomiting , headache , dizziness , numbness , pain or weakness occurs .

fever
any bleeding
headache
numbness
intractable nausea and vomiting
pain
weakness
wound infection
dizziness


white blood cell count on admission 6.1 , inr on admission 1.0 , relevant imaging .

white blood cell count
inr
relevant imaging


the patient was referred to the neurology service for further workup of the mass .


on 5/11/05 repeat imaging revealed some edema and mass affect .


the patient denied blurry vision , headache , nausea , vomiting , paresthesias , pain in mental status , confusion or seizures .

blurry vision
confusion
paresthesias
headache
nausea
vomiting
seizures
pain in mental status


the patient 's pain was initially controlled with iv pain medications but at the time of discharge to the rehab facility he was able to control his pain on po pain medications .


his pathology came back as a large grade iv glioma .


since that time he had been ambulating with a walker and has had increasing difficulty with falls in the last two weeks .


the patient was started on fragmin for dvt prophylaxis and the patient was also started on dilantin levels .


the patient was in previously good health when he reports starting to notice problems ambulating about six months ago .


8. zinc 220 mg po every day .


right lower quadrant scar and inferior midline scar that are well healed .

right lower quadrant scar
inferior midline scar


father with cad at 90 , diabetes , cva , hypercholesterolemia .


transcranial dopplers were checked following surgery and the patient was started on decadron 4 mg q6 to prevent swelling .


moist buccal mucosa , poor dentition , no erythema or exudates in the posterior pharynx .


at the time of transfer , a 16 coude catheter was in place and draining well .


the patient was again seen by his primary care physician and a cg scan revealed a mass in the right parietal lobe .


the staples were removed prior to discharge .


16. neutra-phos 1.25 grams po as needed .


there is increased tone in his right upper extremity with a slight left pronator drift .


echocardiogram june 2004 showed an ef of 77% .


generally a well developed elderly man in no apparent distress sitting in bed .


1. lipitor 40 mg po every day .


of note the patient was seen by cardiology for preoperative assessment .


cranial nerves ii through xii grossly intact with a slight deviation of the uvula and tongue to the right .


right parietal occipital temporal tumor .


3/6 systolic ejection murmur heard best at the apex .


the finding was most consistent with metastatic disease and less likely primary cns neoplasm such as glioblastoma .

primary cns neoplasm
glioblastoma
metastatic disease


the patient did have a postoperative serum sodium in the 120s from the 130s three days postoperatively .


plavix 75 mg every day , lipitor 40 mg every day , hctz 50 mg , monopril 10 mg every day , viagra 100 mg prn .


the patient has a history of laryngeal cancer in 2000 and 2001 , cva in 2001 to 2002 and hypertension , who has a six month history of progressive difficulty in ambulation .

hypertension
cva
laryngeal cancer
progressive difficulty in ambulation


on 5/14/05 mannitol was tapered and then d / c'd.


no nystagmus .


he continued to progress until two weeks prior to admission when he was found in the bathtub , unsteady and fell trying to steady himself .


prominent salivary glands bilaterally .


7. dilantin 100 mg iv tid which can be changed to a po regimen in seven days .


no cva tenderness .


the patient was given an iv load of decadron and restarted on iv decadron which was eventually transferred to po decadron .

iv decadron
po decadron
an iv load of decadron


he has had uncoordination of his feet and began having a cane four to five months ago with the increasing weakness .

the increasing weakness
uncoordination of his feet


the abdomen was soft , nontender , nondistended , positive bowel sounds .


ct shows a right parietal hyperdense and heterogenously enhancing mass measuring 6.5 x 5 cm with the surrounding vasogenic edema in effacement of the right lateral ventricle .


12. levofloxacin 500 mg po q daily x10 days .


at the time of transfer the patient was stable and needed only physical and occupational therapy .


on may 5 , 2005 the patient was taken to the operating room for a right parietal occipital craniotomy and debulking of the tumor using stulz neuro navigation .

stulz neuro navigation
a right parietal occipital craniotomy
debulking


the patient instructed to call dr. coma 's office at 496-260-3297 to arrange for a follow up appointment in the saintaelfoote hospital at the first available time , one to two months after surgery .


3. nexium 40 mg po every day .


an endocrine consult was obtained to help manage his serum electrolytes .


2. captopril 12.5 mg po tid .


of note on 5/9/05 the patient was seen by urology due to an inability to void and a 16 french coude catheter was placed .


no petechiae .


the patient had a relatively unremarkable course and his neurologic status continued to improve following the operation .


5. ativan 0.5 mg po q4 hours prn for anxiety .


6. allegra 60 mg po bid .


mri showed a large heterogenous enhancing right parietal mass lesion with a possible ependymal spread .


9. vitamin c 500 mg po bid .


the patient had no complaints of pain .


5/5/05 right parietal occipital craniotomy and debulking of tumor using stulz neuro navigation .

stulz neuro navigation
debulking of tumor
right parietal occipital craniotomy


10. flomax 0.4 mg po every day .


please see the separately dictated operative report for further details of the procedure .


the patient then was given voiding trials but eventually he needed to be straight cathed prn .


the patient is a pleasant 83-year-old retired psychiatrist who presents with a chief complaint of gait difficulty for the last five to six months .


the patient has seen his primary care physician who referred him to physical therapy for his gait weakness but his symptoms failed to improve .


the patient was started on three grams of sodium , 3x a day with fluid restriction .


the patient is hard of hearing .


no egophony .


the patient was having a hard time walking and reports that he has felt weaker .


no palpable thrill or heave .


his partner also reports that he has been having more difficulty with adls .


11. fragmin 2500 units subcut every day .


the patient was also started on mannitol .


the patient is asked to take a course of dilantin for ten more days .


4. colace 100 mg po bid .


13. dexamethasone 4 mg po q6 hours .


crackles in the right lung field .


no retinal hemorrhages .


15. regular insulin sliding scale with finger sticks qac and qhs .


14. the steroid will be kept for now and tapered at a later date on follow up with dr. coma .


is significant for spinal stenosis and a series of operations including repair of a ureteral stricture ; cataract implants ; two partial hysterectomies ; and an appendectomy .

an appendectomy
cataract implants
operations
two partial hysterectomies
repair


the blood pressure was 150/86 ; pulse 82 ; respirations 16 .


no known drug allergies .


aspirin 325 mg po q.day .


there were no complications , and the patient tolerated the procedure well .


she described the pain as being exacerbated by eating and described an associated weight loss .


findings included no gross evidence seating in the abdominal wall ; one nodule on the posterior surface of the right lobe of the liver ; one nodule in the inferior edge of the falciform ligament .


at the time of discharge , cytopathology specimens had been negative , and surgical pathology specimens were still pending .

surgical pathology specimens
cytopathology specimens


oxycontin 10 mg po q.day .


specimens sent to pathology included peritoneal washings and permanent specimens from the liver and falciform nodules .

permanent specimens from the liver
peritoneal washings
specimens


pancreatic carcinoma .


she was then referred to the fairm of ijordcompmac hospital under the el memorial and was seen by dr. blinjesc , who scheduled her for an exploratory laparoscopy .


she presented to her primary care physician , dr. tlandtaze , in aersing rocuch sun , who obtained a ct scan , which demonstrated a mass in the tail of the pancreas .


postoperatively , the patient had some abdominal bloating with evidence of subcutaneous emphysema over the abdomen .

subcutaneous emphysema over the abdomen
some abdominal bloating


regular s1 and s2 ; no murmurs .


lungs were clear to auscultation bilaterally .


estratab one po q.day .


the patient was admitted through same day surgery and taken to the operating room where dr. blinjesc , assisted by dr. zockbeathe , performed a diagnostic laparoscopy with peritoneal washings .


she tolerated a full diet well , but continued to have abdominal cramping and a mild ileus for the following three days .


included aspirin 325 mg po q.day .


soft ; nontender ; no palpable masses .


laparoscopy with biopsy for diagnosis .


percocet one to two whenever necessary q. four to six hours for pain .


estratab .


darvocet .


she was uncomfortable and slow to have bowel movements , although she did have flatus .


ms. sterpkoteneish is a 69-year-old woman , who over the past six months has noted increasing pain in her left upper quadrant radiating to the back .


she was treated with repeated fleet 's enemas , and on postoperative day three , she had a number of bowel movements , was considerably more comfortable , and deemed ready for discharge .


she was instructed to call dr. blinjesc for the results of these tests and to follow up with him for further management if necessary .


docusate sodium 100 mg po bid prn ibuprofen 200-600 mg po q4-6h prn pain


nothing in the vagina for 6 weeks - no tampons , no douching , no intercourse .


post dates


if you experience fever > 100.4 , bleeding > 1 pad / hour , foul smelling discharge , abdominal pain , or other worrisome symptoms , please call your doctor or return to the hospital .

fever
bleeding
abdominal pain
foul smelling discharge
other worrisome symptoms


no observed abnormalities


responsible after study for causing admission ) s / p nsvd


ho evaluation


initial newborn exam :


apgars 8,9


ob clinic 2 weeks and 6 weeks , no known allergies


postdates pregnancy


weight :


she had a magnetic resonance imaging study and magnetic resonance imaging angiogram performed which showed a large hemorrhagic lesion on the occipital lobe .

a magnetic resonance imaging study
magnetic resonance imaging angiogram


the patient underwent a number of tests .


on physical examination , she was a very pleasant , moderately obese female in no apparent distress .


sensation was intact to light touch and pin prick bilaterally .


there was a dense hemianopsia on the left side .


father and mother died in their eighties of heart disease .


there was also scattered t2 hyperintense foci within the periventricular and left frontal white matter consistent with small vessel disease , gliosis or demyelination .


the head was normocephalic and atraumatic .


the lungs were clear to auscultation bilaterally , without rales or wheezes .


laboratory studies on admission demonstrated a sodium of 144 , potassium 4.1 , chloride 106 , bicarbonate 20.0 , bun and creatinine 12/0.7 , glucose 99 , white blood count of 5.7 , hematocrit of 40.6 , platelet count of 226 , prothrombin time was 9.4 , partial thromboplastin time was 29 .

platelet count
a sodium
white blood count
potassium
glucose
prothrombin time
creatinine
partial thromboplastin time
chloride
hematocrit
bun
bicarbonate


an echocardiogram was obtained and showed that the ejection fraction was 60% and there was no thrombus .


she also developed what appeared to be urinary tract infection and was placed on po bactrim .


the computerized tomography scan was performed and showed a right occipital hemorrhage .


she continued to have a dense left hemianopsia , but otherwise was neurologically intact .


there were some very rare atrial premature contractions .


the patient was admitted to the hospital for further evaluation and work up .


at that time , she was afebrile and her vital signs were stable .


the patient has no known drug allergies .


the patient had considerable difficulty with left finger-to-nose movement , most likely secondary to hemianopsia .


sensation was intact to light touch , pin prick , and proprioception .


ms. tlandkotesmitskote is a patient who came complaining of feeling dizzy and bumping into objects on her left side .


the heart rate was 53 to 106 .


over the ensuing days , the patient had several episodes of confusion at night .


right occipital hemorrhagic stroke .


so an magnetic resonance imaging angiogram was obtained and showed the right parietal occipital hemorrhage .


the patient is a seventy-one year old female with a history of hypertension who now presents with a right occipital hemorrhagic stroke .

hypertension
a right occipital hemorrhagic stroke


there was no pronator drift .


she also felt dizzy and the room was spinning .


patient had difficulty with tandem gait and fell forward while standing on his his toes .


she also denies having hoarseness , difficulties in finding words , speaking , hiccups , or diplopia .

diplopia
hoarseness
difficulties in finding words
hiccups


the abdomen was soft , nontender , nondistended .


symptoms lasted about five hours and then gradually resolved except for the change in vision .


she denied having any weakness , numbness , or pain .


extremities revealed 2+ pitting edema in the knees bilaterally .


there was no clear enhancing mass , but follow up was suggested .


the patient was discharged on tenormin , 25 mg po qd ; bactrim ds , one po bid x5 days .


a neurosurgery service consultation was obtained and they felt that no surgical intervention was required .


she was afebrile and her vital signs were stable .


however , she was soon moved out of there as her examination appeared to be stable .


there were no ventricular premature contractions .


the mra showed mild narrowing of the left ica just distal to the bifurcation .


a holter monitor was obtained and showed that the patient was in normal sinus rhythm .


there was no nystagmus , except for some fine fast beat nystagmus bilateral extremes of abduction .


she is a seventy-one year old female with a history of hypertension who is in otherwise good health .


atenolol , 25 mg po qd .


she was able to subtract serial sevens , remember three out of three objects after five minutes , and there was notable aphasia or word finding difficulty .

word finding difficulty .
notable aphasia


the neurological examination revealed that the patient was awake , alert and oriented to person , place and time .


on review of systems , the patient denied any history of transient ischemic attacks .


the past medical history is significant for hypertension .


cerebellar examination revealed in intention tremor on the right side .


she also complained of a dull , right sided headache over the right eyebrow .


right occipital hemorrhagic stroke .


his melanoma was originally diagnosed last fall when he presented with lesions in the liver and spleen , and a chest ct showed left upper lobe nodules .

left upper lobe nodules
lesions in the liver and spleen
his melanoma


the neurological examination was nonfocal .


a head ct scan was negative , but an mri scan of the spine showed an l5 metastasis with a fracture and had with epidural and paraspinal extension .

l5 metastasis
epidural and paraspinal extension
a fracture


the episode of potential seizure activity occurred in the setting of a bowel movement and may have been associated with vasovagal activity .

vasovagal activity
potential seizure activity


the blood pressure was 113/70 , pulse 66 , respirations 20 , and a temperature of 96.8 .

pulse
respirations
the blood pressure
a temperature


at that time , he also began radiation therapy to his lumbosacral spine .


mr. patient underwent venogram and inferior vena cava filter placement on february 23 , 1993 and was then he was admitted to the fairm of ijordcompmac hospital for postoperative care .

inferior vena cava filter placement
postoperative care


first , he had right lower extremity swelling and lower extremity noninvasives confirmed the diagnosis of a femoral deep venous thrombosis .

right lower extremity swelling
a femoral deep venous thrombosis


he will be scheduled for an mri scan , neurology consult , and an eeg next week as an out patient .


approximately one week ago , he was admitted to the fairm of ijordcompmac hospital for chemotherapy with dtic and tamoxifen .


in addition , the second major event that had occurred yesterday was a neurologic event of some kind .


the physical examination reveals a pleasant 70 year old male in no acute distress .


the patient has no known drug allergies .


ivc filter placement .


he is continuing on the radiation therapy to date .


an ivc filter placement was accomplished without complication .


in addition , there was a t11 metastasis with cord compression .


mr. patient was a poor candidate for anticoagulation because of his history of metastatic melanoma and the question of cns metastases .


deep venous thrombosis of right lower extremity .


the extremity exam was notable for 2+ pitting edema in the right lower extremity extending to the knee .


the neck was supple , without jugular venous distention or increased thyroid .

jugular venous distention
increased thyroid


the chest was clear to auscultation and percussion .


second , he had a witnessed episode in which his eyes rolled to the back of his head and there was a question of some seizure activity .

some seizure activity
a witnessed episode


he tolerated the procedure well .


in the past , he has not been known to have a history of cns metastases .


decadron 4 mg po bid , dilantin 100 mg po tid .


metastatic melanoma .


there was no appreciable cervical , supraclavicular , axillary , or inguinal adenopathy .


the review of systems is negative , except as above .


regular rate and rhythm , with a i / vi systolic ejection murmur .


heent showed pupils equal , round , reactive to light and accommodation , and extra ocular movements intact .


this is the second fairm of ijordcompmac hospital admission for taroby patient , a 70 year old male with a history of metastatic melanoma .


over the 24 hours of in house hospitalization , he did not have any further neurologic activity and was able to ambulate without assistance prior to discharge .


on february 23 , mr. patient presented to dr. patient 's office with two major symptoms .


41 yo man with crfs of dm type ii , high cholesterol , smoking history , family hx , htn p / w episodes of atypical cp x 1 week , with rest and exertion .

htn
high cholesterol
dm type ii
crfs
episodes of atypical cp x 1 week


atypical chest pain


please use with spacer ( please instruct patient ) ecasa ( aspirin enteric coated ) 325 mg po qd wellbutrin ( bupropion hcl ) 150 mg po bid gemfibrozil 600 mg po bid zestril ( lisinopril ) 20 mg po qd zantac ( ranitidine hcl ) 150 mg po bid serzone ( nefazodone ) 300 mg po qhs zyprexa ( olanzapine ) 5 mg po qhs

wellbutrin ( bupropion hcl )
serzone ( nefazodone )
ecasa ( aspirin enteric coated )
zyprexa ( olanzapine )
spacer
zestril ( lisinopril )
gemfibrozil
zantac ( ranitidine hcl )


will plan on ett .


had chest ct to r / o dissection ( due to back pain ) which was neg.


other diagnosis ; conditions , infections , complications , affecting treatment / stay dm ( diabetes mellitus ) anxiety ( anxiety ) htn ( hypertension ) gerd ( esophageal reflux )

anxiety ( anxiety )
gerd ( esophageal reflux )
htn ( hypertension )
dm ( diabetes mellitus )


holding metformin until friday due to ct with contrast .


ruled out for mi .


here , had t wave flattening laterally and inferiorly with pain that resolved pain free , but not clear that lead placement is the same .


glucophage ( metformin ) 850 mg po tid starting on 10/03/00 ( 10/03 ) actos 30 mg po qd


also has h / o anxiety and gerd .


albuterol inhaler 2 puff inh qid


penicillins


atypical cp


no assoicated sx .


principal discharge diagnosis ; responsible after study for causing admission ) atypical chest pain


repeat exam one month later showed a firm left-sided lobe .


his chest x-ray was normal .


sodium 141 , potassium 4.1 , chloride 104 , bicarbonate 28.8 , bun 17 , creatinine 0.9 , glucose 118 .

bicarbonate chloride glucose bun creatinine potassium sodium


radical retropubic prostatectomy , bilateral lymph node dissection .

radical retropubic prostatectomy
bilateral lymph node dissection


he was discharged home on percocet and keflex .


transrectal ultrasound showed a hypoechoic left-sided mass in the peripheral zone .


his neck was supple with no jugular venous distention or thyromegaly .


he was found on physical exam to have an asymmetric prostate with prominence on the left and a question of a nodule .

a nodule
prominence on the left
an asymmetric prostate


on postoperative day # 6 his low grade temperature resolved .


he had no symptoms of chest pain or myocardial ischemia .


his potassium was 3.7 and his hematocrit 33 .


there was a firm nodule in the left lobe of the prostate in the lateral aspect .


chest was clear to percussion and auscultation .


a cardiology consult was obtained for this episode of diaphoresis with tachycardia , as well as for an ekg being read as having anterolateral changes .

anterolateral changes
tachycardia
diaphoresis


his blood cultures and chest x-ray were negative .


the abdomen was soft and non-tender with no masses or organomegaly .


a repeat ekg showed no changes .


the patient is a 67 year old white male with a recent history of urinary frequency q2-3h , stranguria , nocturia x 3-4 per night .


his urinalysis showed marked occult blood and positive white blood cell screen but was otherwise negative .

positive white blood cell screen
marked occult blood


his postoperative course was remarkable for a low grade temperature to 101.7 .


pt 9.4/10.3 , ptt 27 .


no costovertebral angle tenderness .


a biopsy showed moderately to poorly differentiated grade iii-iv adenocarcinoma on the left .


his white blood count was 7100 , hematocrit 35.9 , platelet count 258,000 .

platelet count
his white blood count
hematocrit


his jackson-pratt drained about 35-40 cc per day and was discontinued on postoperative day # 3 .


significant for non-insulin diabetes mellitus , for which he takes diabeta , one qd ; right eye cataract , operated on three years ago .

non-insulin diabetes mellitus
right eye cataract


he was afebrile postoperatively with vital signs stable .


his genitourinary exam showed an uncircumcised male with normal scrotal contents .


a radical retropubic prostatectomy with bilateral lymph node dissection was done .

bilateral lymph node dissection
a radical retropubic prostatectomy


he is allergic to motrin .


pulses 2+ .


he also had a 3-4 year history of impotence .


prostate cancer .


the remaining unit of autologous packed red blood cells was transfused .


regular rate and rhythm with normal s1 and s2 , no murmurs .


no clubbing , cyanosis or edema .


diabeta , one qd .


he subsequently did well , with a repeat hematocrit of 34.3 after the transfusion .


on that day he was slightly diaphoretic with some tachycardia to 100 .


ekg :


his creatinine was 1.2 on postoperative day # 5 .


his hematocrit on 07/03 was 28.1 .


his vital signs were stable .


the patient was managed with vasotec , nifedipine and clonidine with blood pressure under good control at the time of discharge , average 125 systolic , 70 diastolic , heart rate of 72 .

blood pressure
systolic
heart rate
diastolic


cardiovascular exam :


electrolytes were within normal limits , glucose 192 , bun and creatinine 9/0.7 , hematocrit 49.5 , white blood count 7.9 , platelet count 166,000 , 65% polys , 3 bands , 24% lymphs .

electrolytes
glucose
platelet count
hematocrit
polys
lymphs
white blood count
bun
creatinine
bands


the electrocardiogram showed normal sinus rhythm with old q wave inferior myocardial infarction .


right thalamic hemorrhage , hypertension , diabetes mellitus .

hypertension
right thalamic hemorrhage
diabetes mellitus


the cranial nerves showed full visual fields without extinction , pupils 5 to 3 bilaterally and equal , disks flat , lower left facial decreased sensation to temperature , pin prick on the left v1 through v3 , tongue deviates to the left , good gag , decreased shrug on the left .


he was unable to move the left side of his body and felt numb on that side .


the abdomen was soft and non-tender , obese , with normal bowel sounds .


his voice became slurred and he had a mild central dull headache .


vasotec 40 mg q.day , soma 1 tablet q.day , demerolprn , clonidine .


vasotec 20 mg po b.i.d. , clonidine 0.2 mg po b.i.d. , nifedipine 20 mg po t.i.d. , flexeril 10 mg po t.i.d. , valium 5 mg po t.i.d. , micronase 1.25 mg q.day .

valium vasotec clonidine micronase flexeril nifedipine


the neurological examination on discharge was no movement in the hand on the left or arm .


on sensory examination , had decreased pin prick , temperature , vibration in the left side of the body .


on physical examination , patient is in no acute distress , afebrile , blood pressure 134/80 , heart rate 80 and regular , no bruits .

on physical examination
blood pressure
heart rate


the patient has a history of adult onset diabetes mellitus , ankylosing spondylitis , status post myocardial infarction in '96 ( ? ) now with acute onset of left face and arm greater than leg hemiplegia and primary hemisensory loss on the left .


the patient was started on 2.5 of micronase with resulting sugars as low as 63 , decreased to 1.25 mg q.day .


on the lower extremity , could wiggle toes , flexor and plantar , 3+/5 , quadriceps 4/5 on the left .


he denies any visual symptoms or cortical-type symptoms .


he was taken to wayskemedcalltown talmi and transferred to heaonboburg linpack grant medical center with a computerized tomography scan showing a 1x2 thalamic capsular hemorrhage without superficial mass effect .

superficial mass effect
a 1x2 thalamic capsular hemorrhage


the chest x-ray was clear .


3. diabetes mellitus .


2. hypertension .


back and neck were stiff and sore , without localizing tenderness .


muscle spasms were managed with flexeril 10 po t.i.d.


the patient has no known drug allergies .


the family history is positive for diabetes mellitus , positive for cancer .


the patient is a 58 year old right hand dominant white male with a long history of hypertension , changed his medications from aldomet to clonidine six weeks ago .


three on the left knee , 4 on the left ankle with upgoing toe and clonus on the left .


also managed with valium 5 mg po t.i.d.


motor examination showed full power on the right arm and leg , could barely flex fingers of the left hand , pulls left arm medially only .


regular rate and rhythm with a i/vi systolic ejection murmur .


head computerized tomography scan showed 1.5 to 2 centimeter bleed in the right thalamus extending to the internal capsule with mild distortion only , no shift .


on reflex examination , 2 on the right upper extremity , 2+ on the left upper extremity , 2 on the right knee , 0 on the right ankle , with down going toe on the right .


on neurological examination , mental status alert and oriented x three , good memory , fluent speech , good repetition and naming .


his lungs were clear to auscultation and percussion .


his blood pressure was 220/110 there .


the patient was found to be allergic to percocet and percodan during his hospital course .


the finger-to-nose was okay on the right .


this will be followed by a trial of coumadin , and then by mitral commissurotomy or replacement and probable tricuspid annuloplasty by dr. riemund c. wave .

tricuspid annuloplasty
mitral commissurotomy
coumadin
replacement


digoxin 0.125 mg q.d. , lasix 80 mg q.a.m. and 40 mg q.p.m. aspirin 1 q.d. , and vanceril three puffs b.i.d.


superficial varicose veins .


coumadin has caused bleeding from the mouth and nose on two occasions , on one occasion with prothrombin time 13 , and has been replaced by anti-platelet agents .


she has had one gram per day proteinuria with normal creatinine .


she has been treated with vanceril for chronic obstructive pulmonary disease .


she has had an appendectomy and cholecystectomy .


hematocrit 44 , potassium 4.0 , bun 23 , creatinine 1.2 , blood sugar 115 , digoxin 1.4 .

hematocrit
creatinine
potassium
bun
digoxin
blood sugar


right ventricular heave .


because it would be ideal to place a mechanical valve if valve replacement rather that commissurotomy is needed , she was seen by dr. ca shuff of ent for her history of epistaxis .

commissurotomy
valve replacement
a mechanical valve


chest x-ray showed left atrial , right ventricular and pulmonary arterial enlargement and interstitial edema with small , bilateral effusions .


no s3 or opening snap .


tricuspid regurgitation , heart failure , chronic atrial fibrillation , chronic ventricular ectopy , chronic obstructive lung disease .

tricuspid regurgitation
chronic ventricular ectopy
heart failure
chronic obstructive lung disease
chronic atrial fibrillation


she has now had progressive heart failure .


s2 narrowly physiologically split with accentuation of p2 .

accentuation
narrowly physiologically split


the procedure could not be scheduled during this admission .


apical impulse not palpable .


electrocardiogram showed atrial fibrillation , moderate ventricular response , incomplete right bundle branch block , right axis deviation , right ventricular hypertrophy and possible apical infarction .

atrial fibrillation
moderate ventricular response
right axis deviation
right ventricular hypertrophy
incomplete right bundle branch block
apical infarction


there was minimal aortic valve calcification , mild ______________ thickening , normal open , and mild aortic regurgitation .

minimal aortic valve calcification
mild ______________ thickening
mild aortic regurgitation


liver slightly pulsatile but no enlarged .


she has had recurrent syncope since age 6 .


transdermal nitroglycerin caused headache .


fvc was 1.6 or 58 percent of predicted and fev1 0.95 or 45 percent of predicted .


a holter showed atrial fibrillation with period of ventricular bigemini .

atrial fibrillation
ventricular bigemini


right atrial pressure was 12 with a wave form consistent with tricuspid regurgitation .


potassium replacement has caused , according to the patient , marked hyperkalemia in the past .


the patient is , therefore , discharged after a three day hospitalization , with plans for re-admission for the neuroradiology procedure .


pulmonary capillary wedge pressure was markedly elevated at 38 , with a very large mitral valve gradient .

markedly elevated
a very large mitral valve gradient


she has not had hypertension or diabetes , and says he has lowered her cholesterol from 333 to 197 by changing her diet .


there was little or no aortic valve gradient .


epistaxis to coumadin in the past .


pulses normal to the femorals with weak dorsalis pedis pulses .


there was no tricuspid valve gradient .


arterial oxygen saturation was 85 percent .


she had a partial gastrectomy in 1972 for a " tumor " .


he identified no bleeding source , but felt that the risk of nasal hemorrhage on coumadin could be minimized interventional neuroradiology occlusion of the arteries to the nose bilaterally .

coumadin
interventional neuroradiology occlusion


there was minimal mitral valve calcification , normal left ventricular contraction , and 2+ mitral regurgitation into a large left atrium .


in the meantime , lasix dosage is increased .


cardiac catheterization 11/03 .


cardiac catheterization was performed without complication from the right neck and right groin on the day of admission .


heart rate 86 , irregularly irregular , blood pressure 142/86 .


there is no family history of heart disease .


grade ii decrescendo diastolic murmur at the left lower sternal border .


room air arterial blood gas was 56/40/7.45 .


digoxin 0.125 mg po q.d. , lasix 40 mg b.i.d. , aspirin held , and vanceril three puffs b.i.d.


mitral stenosis


neck veins distended .


this 68-year-old patient of dr. naka jesc had two episodes of rheumatic fever as a teenager .


grade ii systolic murmur at the left lower sternal border .


fich cardiac output was 3.0 and indexed 2.0 .


pulmonary artery pressure was markedly elevated at 120/60 .


there was mild atherosclerosis of the mid left anterior descending .


diastolic rumble at the apex .


she has had chronic atrial fibrillation .


no edema .


pulmonary function test 11/04 .


flank pain uri ?


return to the er for high fevers , vomiting , uncontrolled pains or other concerns as needed .

uncontrolled pains
high fevers
other concerns
vomiting


exam , urinalysis , medication


levofloxacin 500 mg every day for 7 days


urinary tract infection


the patient was given printed instructions for urinary tract infection ( portugese ) .


he was admitted on 06/07/00 for a matched , unrelated donor bone marrow transplant .


on 06/26/00 due to agitation , change in mental status and increased respiratory distress , the patient was intubated .

agitation
increased respiratory distress
change in mental status


although the patient 's pain and sedation meds were adjusted he continued to be agitated and there was difficulty weaning him off the vent .


1. status post bone marrow transplant .


neurosurgery was consulted but due to the severity of the bleed surgery was not considered an option .


mr. larsen was a 50-year-old salesman who in 12/26 was noted to have an elevated platelet count of 778,000 .


white blood cell count of 24.409 and platelets of 956,000 .


it was felt at that time that the changing mental status and respiratory distress might be due to a combination of medication and worsening mucositis .

respiratory distress
the changing mental status
worsening mucositis


chronic myelogenous leukemia


his course was then complicated by fevers and neutropenia which were treated with antibiotics and a diffuse erythroderm felt to be a drug reaction .

a drug reaction
fevers
neutropenia
a diffuse erythroderm


because of this continued agitation , a head ct was performed on 07/01/00 and it revealed an intraparenchymal hemorrhage .

this continued agitation
an intraparenchymal hemorrhage


the patient received his bone marrow transplant on 06/12/00 .


cml .


a bronchoscopy was done and there was blood found in the upper airways but no evidence of blood in alveoli so it was not felt to be dah .


on 06/24/00 the patient was found to have pulmonary infiltrates and some hemoptysis .


the patient gradually lost brain systolic ejection murmur function and was pronounced dead on 07/02/00 .


2. intraparenchymal bleed .


he was found to have cml .


uric acid 4.7 , cholesterol 150 , triglycerides 74 , hdl 44 , ldl 91 .

cholesterol
triglycerides
ldl
uric acid
hdl


her speech was fluent with no phasic or praxic problems , dysarthric .


father and brother died of pe .


hypertension .


she did not complain of headache , diplopia , or any other neurological symptoms .

diplopia
headache
any other neurological symptoms


given the localization of the hematoma and the history of hypertension , the most likely cause for mrs. dua 's cerebellar hemorrhage is hypertension .

the hematoma
hypertension
hypertension
cerebellar hemorrhage


twenty-four urine for catecholamine , metanephrines , and vma pending at the time of discharge .

twenty-four urine
vma
catecholamine
metanephrines


a magnetic resonance imaging study will be scheduled as an outpatient in three months to rule out a small vascular malformation if responsible for the hemorrhage .

a small vascular malformation
the hemorrhage


so far no secondary causes of hypertension were identified but causes like lymphocytic ? chromocytoma or renal artery stenosis have not been ruled out yet .

renal artery stenosis
lymphocytic ? chromocytoma
secondary causes
hypertension


protein c , protein s and plasminogen level within normal limits .


normocephalic , atraumatic , anicteric .


hydrochlorothiazide 25 mg. po q.day , captopril 75 mg. po three times a day , nifedipine 40 mg. po three times a day .


her hypertension was difficult to manage initially and required three days of intensive care unit with a-line and nipride intravenously .


regular rhythm with no murmur , rub or gallop .


no evidence of pulmonary emboli .


bowel sounds present , soft , nontender , nondistended , guaiac negative , no hepatosplenomegaly .


urine culture negative .


the deep tendon reflexes were 2+ on the left side , 1+ on the right side .


she was then transferred to ro woodma healthcare for further management .


sodium 140 , potassium 4 , chloride 107 , co2 25.4 , bun 9 , creatinine .8 , blood sugar 130 .

sodium
potassium
blood sugar
creatinine
chloride
co2
bun


sinus rhythm at 116 , axis of 23 , intervals of .14/ .07/ .42 , no st-segment abnormalities .


supple , no bruits .


white blood cell count 9.8 , hematocrit 44.1 , platelets 262 , prothrombin time 10.4/ 10.3 , partial thromboplastin time 25.9 .

platelets
prothrombin time
hematocrit
white blood cell count
partial thromboplastin time


her speech became slurred , this was followed a few seconds after by weakness and numbness of her arm and leg .


specific gravity 125 , ph 6 .


no clubbing , cyanosis or edema .


head computerized tomography scan on 10/19 : 3 centimeter hyperdensity within the right putamenal area in the right external capsusle consistent with intra-parenchymal hematoma with mild local mass effect and surrounding edema .

intra-parenchymal hematoma
mild local mass effect
3 centimeter hyperdensity
surrounding edema


the exam is remarkable for a mild leftsided face , arm and leg weakness and sensory deficit that should further improve with physical therapy and occupational therapy help .

arm and leg weakness
sensory deficit
a mild leftsided face


the fine motor movements of the left hand were diminished , there was a mild dysmetria on the left side to finger / nose and heel / shin .

a mild dysmetria on the left side
diminished


urinalysis :


it was finally under control with high doses of captopril , nifedipine , and hydrochlorothiazide .


the workup to rule out secondary cause of hypertension given the patient 's young age and the difficulty controlling the blood pressure was started as an inpatient and will be completed by dr. ______________as an outpatient .


on sensory exam there was a mild diminution of light touch , pinprick , position , and vibration sense in the left side .


she is now able to walk fitfully and use her left hand with no problem .


the area of hemorrhage the same , slightly more edema and mass effect .

hemorrhage
slightly more edema and mass effect


sedimentation rate 2 , antithrombin 3 .


will be reassessed after a month of intensive physical therapy and occupational therapy .

occupational therapy
intensive physical therapy


thyroid stimulation hormone 1.9 .


a 34 year old white female lying in bed , anxious ; blood pressure of 220/120 , afebrile .


mrs. dua is a 34 year old white female with an unclear history of hypertension for at least five years .


pulmonary angiogram :


there was a left central facial paresis .


she was in her usual state of health until around 12:40 on october 19 , when while on the phone , started to have difficulty in talking .


pupils were 2 millimeters down to 1 millimeter by direct and consensual stimuli .


no lesions .


head computerized tomography scan of 10/23 :


there was a left arm pronator .


electrocardiogram :


chest x-ray negative .


right capsular putamenal hemorrhage .


she does not smoke , does not use birth control pills , does not use drugs .


clear to auscultation .


dexamethasone suppression test negative with a cortisol level at 8 a.m. of 1.7 .

a cortisol level
dexamethasone suppression test


v1 through v3 , diminished light touch and pinprick in the left side .


visual fields were full to confrontation .


she was seen at a memorial hospital where her blood pressure was measured at 240/120 and was found to have a mild left hemiparesis .


urine and serum toxicology screen negative .


no other areas of hemorrhage identified .


the walk was paretic in the left side .


gag was symmetric .


vaginal delivery with second degree laceration


efw = 7# .


ctx q 6 ' .


height 63 heent normal mouth normal neck normal breasts normal no masses nipples normal chest normal cta bilat , neg wheezing cor normal nsr , no murmur abdomen gravid , vtx .


abnormal laboratory result ; abnormal pap test ; monilial vaginitis

abnormal laboratory result
abnormal pap test
monilial vaginitis


extrem normal skin normal nodes normal vulva normal vagina leaking copious amounts clear fluid .


she delivered a 3235 gram male infant on 11/01/2004 at 09:31 am with apgar scores of 9 and 9 at one and five minutes respectively at 39.0 weeks gestation via spontaneous vertex vaginal delivery .


sse and digital exam deferred cervix digital exam deferred at time of admission os normal see above adnexae normal non-palp d / t advanced gest uterus gravid , vtx .

digital exam
adnexae
cervix digital exam
os
sse


multivitamins and folate


mild irreg. ctx .


premature rupture of membranes .


fhts 140s w/ reactivity .


spontaneous vertex vaginal delivery


fluid amnioswab and fern positive .


routine post partum care


premature rupture of membranes


uterine size in weeks 38


your patient was admitted under the care of aner , aea m with a preliminary diagnosis of line sepsis .


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


the patient presented with a chief complaint of fever .


a left breast lumpectomy was reportedly benign .


seventh nerve weakness on the right in a central pattern is present .


metamucil 1 teaspoon q.d. , with first bolus of juice , juice 250 cc. down nasogastric tube t.i.d. , tube feeds as above , lactinex as above , tagamet 800 mg. nasogastric tube qhs , nystatin swish and spit 10 cc. five times a day , cardizem slow release 90 mg. po q.d. , folic acid 1 mg. po q.d. , ciprofloxacin 500 mg. po b.i.d. , discontinue on 12/10/92 kayciel 30 meq. down nasogastric tube q.d. , peridex 10 cc. swish and spit q.i.d. , coumadin 4 mg. nasogastric tube on odd days , alternating with 5 mg. nasogastric tube on even days , once daily , tylenol 650 mg. po and pr q6hours prn pain , nystatin powder to axilla and groin as needed .

nasogastric tube
juice
nasogastric tube
cardizem slow release
coumadin
folic acid
peridex
lactinex
tylenol
tagamet
nasogastric tube
kayciel
kayciel
ciprofloxacin
juice
nystatin swish and spit
metamucil
nystatin powder
tube feeds


she has been afebrile for greater than 10 days , including several days on oral antibiotics .


for a short time , she seemed " locked in " .


regular rate and rhythm , without ectopy .


mevicor 60 mg. po q.d. , cardizem 90 mg. w release po q.d. , questran one pack q.i.d. , niacin 500 mg. po b.i.d.


she has severe memory deficits , but nevertheless , is able to engage in conversation , answers questions , names things well , does calculations and recognizes family members and states preferences .


this did not normalize with administration of isordil and the patient denied chest pain at this time .


iron studies are all entirely normal , her anemia is attributed to anemia or chronic disease with hypoproliferation as well as multiple phlebotomies .

hypoproliferation
anemia
chronic disease
her anemia


she has developed bad thrush in this setting , she is not yet able to swallow and so she is on nystatin swish and spit five times a day .


the plan is to give her folic acid , but not iron .


the patient needs prothrombin time checked daily , patient needs potassium checked daily , patient needs sodium checked at least every other day .


the cranial nerve exam :


follow up computerized tomography scans and magnetic resonance imaging studies have shown infarction in bilateral basis pontis , mid brain , the superior cerebellar areas , left thalamus , bilateral temporal lobes medially and inferiorly and left posterior communicating artery .

magnetic resonance imaging studies
computerized tomography scans


she did have brief chest pain twice during this admission that did not correlate with electrocardiogram changes .


sensory limb of the right eye corneal reflex is slowed , otherwise normal .


in the first week of november , her electrocardiogram showed t wave inversions in the lateral leads , correlating with an increase in the ldh , but not ck .

t wave inversions in the lateral leads
an increase


she has been working with speech therapy , occupational therapy and physical therapy closely and should continue to show improvement .

occupational therapy
physical therapy
speech therapy


anemia , discharge hematocrit 28 , not iron deficient .


includes recent infarct to pons , mid brain , left thalamus , bilateral temporal lobes and left visual cortex , on coumadin .


normal pulses , no clubbing , cyanosis or edema .


once her liver enzymes are completely normal , a seven day course of fluconazol may be helpful if the thrush is not spontaneously resolving off of antibiotics .


the day of discharge is day #3 of 7 , after which antibiotics should be totally discontinued .


sputum grew out klebsiella pneumoniae , and she was treated with gentamicin and ancef for 14 days intravenous ( bug being sensitive to these two drugs ) .


the patient is a 68 year old , right handed caucasian female , former r.n. who complained of several days of vertigo , one day of double vision , dysarthria and worsening of vertigo .

vertigo
vertigo
double vision
dysarthria


hypertension for 20 years , high cholesterol , coronary artery disease with episodes of angina , no history of myocardial infarction , exercise treadmill or evaluation .

high cholesterol
angina
coronary artery disease
myocardial infarction
hypertension


this may due to her central nervous system process or her pulmonary process , with fluids administered as described , she should not have any problems from this .

any problems
her pulmonary process
her central nervous system process


the patient had fevers sporadically during this hospitalization with rising white blood counts .


sensory exam was not remarkable , cerebellar exam was not possible .


she also gets lactinex granules three packages in each bottle of tube feeds .


note that the liver enzymes were normal on admission , at which time she was taking all of the above cholesterol medicines .


a left pleural effusion developed and this was tapped with ultrasound guidance , and found to be sterile , and without evidence of empyema .


a small intimal tear in the arch of the aorta during the angiogram , was without sequelae .


pupils reactive to light , extra ocular movements show good upgaze up to 3 mm. , good down gaze .


soft , without hepatosplenomegaly .


admitting creatinine was .7 , glucose 131 , white blood count was 10,000 , hematocrit was 40 , liver enzymes normal range .

admitting creatinine
hematocrit
liver enzymes
glucose
white blood count


right lateral gaze , the right eye had 2 mm. of sclera showing , the left eye was normal , and there are a few beats of right beading nystagmus .


she is anticoagulated on coumadin and this has been stable .


she has had an inguinal hernia repair .


initially this improved on clindamycin and cefotetan , but fevers recurred on this antibiotic regimen .

cefotetan
this antibiotic regimen
clindamycin


the patient was taken to the intensive care unit after her angiogram .


an magnetic resonance imaging study showed basilar artery disease , questionable aneurysm .


the patient 's liver enzymes were noted to be elevated mid way through her hospital course , to about three times normal , especially the sgot and sgpt .


she also gets peridex to clean out her mouth .


a chest x-ray showed some left lower lobe atelectasis .


full strength replete with fiber at 70 cc. per hour .


low sodium , responsive to fluid restriction .


she also gets metamucil one teaspoon with the first bolus of juice each day .


tibialis 3 on the left , 5+ on the right .


a chest x-ray documented a progressing left lower lobe infiltrate .


her tube feeds orders are as follow :


these can be restarted when it is deemed reasonable , in view of her acute disease and recently elevated liver enzymes .

recently elevated liver enzymes
her acute disease


gastroc. 3 on the left and 4+ on the right .


low potassium , thought due to gentamicin .


a right upper quadrant ultrasound documented gallstones , without evidence of common bile duct dilatation or active cholecystitis .

common bile duct dilatation
active cholecystitis
gallstones


her blood pressure was 190/90 when i first saw her on her second hospital day .


as of 4/7 , her electrocardiogram had reverted back to normal and there is no evidence of congestive heart failure or continued electrocardiogram changes , and chest pain is absent .


her sodiums were never below 130 .


an angiogram on 11/3 was consistent with thrombosis at the mid basilar artery .


left lower lobe pneumonia , resolving now on oral antibiotics .


she was doing well with at least 4+ strength in all of her extremities , when on 11/13 , she had an acute drop in her systolic blood pressure to 70 for unclear reasons and without evidence of acute sepsis .


she was aggressively anticoagulated with heparin .


she was afebrile , in sinus rhythm , pulse 60 .


quadraceps 2+ on the left and 3+ on the right .


the patient has had low sodiums during this hospitalization .


basilar artery stenosis with basilar thrombosis and " top of the basilar " syndrome .


gallstones , thought to be inactive .


she is drowsy at times , but generally alert , responsive , interactive , able to talk in two to three word sentences when she wants to .


in addition , the patient gets 250 cc. of juice ( not water ) three times a day .


the patient had a steady decline in her hematocrit during this hospitalization .


she was seen at the outside hospital and put on aspirin for two days .


please note that evaluation by the swallowing therapist , showed that the patient is aspirating at this time , but there is great hope from the nature of her deficit and the good movements of her tongue that normal swallowing should return soon .


this was accompanied by substantial decrement in neurologic function .


high cholesterol .


the patient 's potassiums have been repeatedly low and require daily checks and repletion .


reflexes were diffuse 3+ , toes upgoing bilaterally .


the left lateral gaze , the left eye had 1 mm. of lateral sclera showing .


ck 's were mildly elevated but the mb fractions were not remarkable .


the patient has no known drug allergies .


it is for this reason that she is discharged with an nasogastric tube and that no plans for g tube placement are made at this time .


motor exam showed greater than 4+ strength bilateral upper extremities and psoas unable to lift off bed .


her cholesterol was 350 here .


the exact cause of her liver enzyme elevation is unclear , but we are being careful about administering drugs , which might irritate the liver .


she does well with tube feeds .


the patient is on ciprofloxacin .


this must be carefully checked despite the standing order for potassium .


she has a history of of angina without myocardial infarction that has not been worked up .


a ii / vi systolic ejection murmur is at the base , minimal radiation to the carotids .

minimal radiation to the carotids
a ii / vi systolic ejection murmur


post angiogram her eyes were closed .


history of coronary artery disease .


this is thought due to the extensive course of gentamicin which she received .


she has been off of her hypercholesterol medicines .


improving liver enzyme elevation .


on admission , electrocardiogram showed less than 1 mm. of st depression in v4 to v6 , which is likely the patient 's baseline .


the patient was put on heparin and was stable since .


thrush .


she was very responsive , somewhat sleepy , she complained of chest pain , which was diffuse , non-localizing without electrocardiogram changes and persisted for several days and then went away completely .


the neurological examination :


likely recently passed kidney stone


also please follow up with urology regarding management of your kidney stones .


the patient was given printed instructions for kidney stones ( english ) .


history , physical , lab , abdominal ct scan


motrin as needed


please return if your symptoms return , you develop a fever .


rlq pain


the patient presented with a chief complaint of iv fluids .


following triage , the patient left without treatment .


she had no lachmann or anterior drawer , she did have a mild effusion .


anxiety neurosis for which she has received shock therapy in the past .


the foley catheter was removed on 6/29 and she had no difficulties voiding .


left total knee arthroplasty on 6/26/90 .


doxepin causes itching .


her hematocrit was 31.4 on 6/29 with a pt of 18.2


her pt drifted down to a level of 12.9 by 7/3 and therefore she will be discharged with 4 mg of coumadin per day to be followed by the coumadin clinic at cowerin tonli medical center .


psychiatry service saw her on 6/28 and recommended avoiding benzodiazepines and haldol for agitation .


potassium 4.4 .


she was therefore taken to the operating room on 6/26 and underwent a left total knee arthroplasty losing 200 cc of blood in the procedure with two drains left in which were removed on the first postoperative day .

the procedure
two drains
a left total knee arthroplasty


mri demonstrated a left femoral condyle osteonecrotic defect and degenerative meniscus .


her ekg was normal .


since that time , she has used a cane and she was referred to dr. koors .


she developed no problems with edema or with her wound during her hospital stay .


she was discharged with a prescription for tylenol #3 with physical therapy .


her left knee had 5 degrees of valgus , 120 degrees of flexion , full extension and slight valgus instability .


she was slightly agitated on the first postoperative day but this resolved by the second postoperative day .


the patient is a 78-year-old female who has had osteoarthritis and noted the sudden onset of left knee pain in 09/89 .


her epidural catheter was removed on 6/29 .


hepatitis 35 years ago .


she presented for an elective left total knee arthroplasty .


she was prophylaxed with kefzol perioperatively and with coumadin postoperatively .


on admission included a hematocrit of 34.2 .


she did quite well with physical therapy and was ambulating with a walker and crutches by 7/3/90 .


pneumonia one and a half years ago .


on admission included tylenol .


she can one walk without difficulties .


she was also given whiskey spirits because of the fact that she drank one to two drinks of scotch per day .


the patient was cleared for surgery by dr. lupevickette ca .


she climbs stairs one at a time and denied rest pain .


left knee osteoarthritis .


total abdominal hysterectomy .


on admission was only significant for her orthopaedic exam .


he was given lasix 40 mg iv x 1 and also had nitro paste around the time of his surgery and beta blocker .

lasix
nitro paste
beta blocker
his surgery


left proximal humerus fracture .


colace 100 mg. p.o. t.i.d. senokot 1 p.o. q. h.s. nystatin powder to affected area t.i.d. lopressor 25 mg. p.o. b.i.d. atrovent 0.8/2.5 c.c. normal saline nebulizers q. 8 h. albuterol 2.5/5 c.c. normal saline nebulizers q. 4 h. with q. 2 h. p.r.n. percocet 1-2 p.o. q. 4 h. p.r.n. pain .

colace
senokot
atrovent
normal saline nebulizers
lopressor
albuterol
nystatin
percocet
normal saline nebulizers


adult-onset diabetes mellitus x 40 years , history of silent myocardial infarction , coronary artery bypass graft ( three vessels in 1987 ) , history of chronic , stable angina pectoris , fournier 's gangrene versus necrotizing fasciitis , congestive heart failure in 03/97 while in the hospital for a rib fracture , glaucoma , diabetic retinopathy with blindness in the right eye , history of gastric stapling , left rib fracture , right femur surgery .

congestive heart failure
blindness in the right eye
diabetic retinopathy
chronic , stable angina pectoris
fournier 's gangrene
glaucoma
silent myocardial infarction
necrotizing fasciitis
adult-onset diabetes mellitus
left rib fracture
a rib fracture

coronary artery bypass graft
gastric stapling
right femur surgery


prilosec 20 mg. p.o. b.i.d. vexol 1% 1 gtt od b.i.d. lasix 40 mg. p.o. q.d. kcl 20 meq p.o. q.d. tylenol 650 mg. p.o. q. 12 h. p.r.n. ativan 1 mg. p.o. q. h.s. p.r.n.


the patient transfused 2 units on 10/15/97 for a hematocrit of 27.6 .


the patient also had a shoulder film done on 10/10/97 that showed a severely comminuted fracture of the proximal left humerus with proximal distraction .


this ct scan , done also on 10/10/97 , again showed the severely comminuted fracture of the proximal left humerus .


an echocardiogram was performed on columbus day which showed an ejection fraction of 50% , left atrial enlargement , thickening of the aortic wall consistent with atherosclerotic changes , left ventricle size , and systolic function within normal limits .

thickening of the aortic wall
atherosclerotic changes
left atrial enlargement


cholecystectomy .


sodium 135 , potassium 4.1 , chloride 101 , c02 28.4 , bun 17 , creatinine 1.0 , glucose 302 , calcium 8.6 , phosphorus 2.5 , magnesium 1.6 , total protein 6.7 , albumin 3.3 , globulin 3.4 , uric acid 6.3 , totalbilirubin .7 , alkaline phosphatase 93 , sgot 20 , ldh 258 , cpk 95 , whiteblood count 15.3 , hematocrit 49.7 , platelet count 159 , mcv 98 .

whiteblood count
bun
globulin
c02
glucose
albumin
sodium
platelet count
calcium
chloride
hematocrit
ldh
magnesium
alkaline phosphatase
creatinine
totalbilirubin
sgot
potassium
mcv
phosphorus
uric acid
total protein
cpk


ocufen 0.03% 1 gtt od t.i.d. vasotec 20 mg. p.o.q. a.m. prozac 40 mg.p.o.q. a.m.


he does become slightly short of breath when lifting furniture .


the patient 's admitting chest x-ray showed an elevated left hemidiaphragm consistent with atelectasis versus splinting on that side .

atelectasis
an elevated left hemidiaphragm
splinting on that side


non-focal , except unable to assess left upper extremity secondary to the patient 's broken humeral fracture .


his bun/ creatinine rose from 16/1.2 on 10/18/97 to 25/1.9 on 10/18/97 to 22/9.1 to today 's labs , which are 15/0.7 on 10/23/97 .


blood pressure 120/70 , temperature 97.8 f , pulse 68 , respirations 22 , sa02 on 2 l 94% .

sa02
pulse
respirations
temperature
blood pressure


abdomen distended , mild tenderness on the left , bowel sounds present , nohepatosplenomegaly .

abdomen distended
mild tenderness on the left
nohepatosplenomegaly


the stomach had evidence of prior surgery and old blood in the stomach .


history of coronary artery disease status post silent myocardial infarction in the past and three-vessel coronary artery bypass graft in 1987 .

silent myocardial infarction
coronary artery disease


the patient was initially on cimetidine and carafate here at bri health , and then switched to prilosec 20 mg bid .


no hemoptysis , hematemesis , abdominal pain , black or tarry stools , dysuria / frequency/urgency .

hemoptysis
hematemesis
black or tarry stools
abdominal pain
frequency/urgency
dysuria


right femur surgery approximately two years ago .


the patient urinalysis on 10/19/97 showed moderate occult blood , ph 5 , albumin 1+ , white blood cells present , 2-50 red blood cell , 10-20 white blood cells , few bacteria , and moderate bladder epithelial cells .

moderate occult blood
few bacteria
moderate bladder epithelial cells

red blood cell
the patient urinalysis
white blood cells
albumin
white blood cells
ph


humulin 70/30 with 30 units subq.q.a.m. and 20 units subq.q.p.m. vasotec 20 mg. q. a.m. prozac 40 mg. q.d. lasix 40 mg. q.d. k-dur approximately 28 ? meq q.d. atropine 1% 1 gtt od b.i.d. ocufen 0.03% 1 gtt od t.i.d. ventolin metered-dose inhaler .

humulin ventolin prozac ocufen atropine k-dur lasix vasotec


elevated left hemidiaphragm of uncertain etiology or duration .


gi was consulted on 10/15/97 for melena , decreased hematocrit prior to his humeral fixation surgery .


the patient presented with a comminuted fracture of the proximal left humerus when he slipped over the stairs , about to board an airplane back to jeglas blvd. , jolouisrowarlihis , alabama 86071 .


coumadin was reportedly discontinued approximately six months ago secondary to planned surgery for diabetic retinopathy and glaucoma .


left shoulder hemiarthroplasty .


the patient received chest physical therapy bid .


during conscious sedation , the patient developed bigeminy ( the patient was sedated , did not feel chest pain or shortness of breath ) .


on the day of admission , when he fell , the patient was experiencing no chest pain , no shortness of breath , and had no loss of consciousness , no head trauma with fall .

chest pain
head trauma with fall
shortness of breath
loss of consciousness


a repeat urinalysis on 10/22/97 was negative .


repleting potassium , magnesium , phosphorus as needed .


atropine sulfate 1 gtt 1% od b.i.d.


fbs less than 200 = 0 units of czi fbs 201-250 = 2 units of czi fbs 251-300 = 4 units of czi fbs 301-350 = 6 units of czi fbs 351-400 = 8 units of czi fbs greater than 400 = 10 units of czi .


innumerable smaller fracture fragments were interposed between the fracture fragment and the distal humeral shaft .

the fracture fragment
innumerable smaller fracture fragments


after his procedure on 10/17/97 , elevated cpks were noted on 10/19/97 to 10/20/97 , and the first level was 744 , cpk # 2 635 , and cpk # 3 461 .


the patient has right facial droop , right ptosis , stable and present for greater than one year .


no chest pain , no shortness of breath , 1+ ankle edema .

chest pain
shortness of breath
1+ ankle edema


cardiology was consulted and aspirin and beta blocker added to his regimen , as well as chest wall nitroglycerin around the time of surgery , which was subsequently discontinued .

chest wall nitroglycerin
beta blocker
his regimen
surgery
aspirin


diabetic retinopathy with the patient blind in right eye .


upper endoscopy x 2 .


left proximal humerus fracture .


right-sided ptosis , right eye not reactive to light , cataract present , patient blind in that eye , left eye reactive to light , cataract also present in that eye .

blind in that eye
right-sided ptosis
cataract
cataract


mb fractionations of the cpks were all negative and were thought to be secondary to the patient 's beginning physical therapy on 10/19/97 , and all muscular in origin .


a lucency and irregularity of the glenoid , possibly representing a fracture , was also seen , and a ct scan was therefore obtained in order to evaluate this area .


the fracture fragments retained their proper site of articulation with the glenoid fossa .


no known drug allergies .


left rib fracture .


a bone density scan would be recommended as an outpatient , in order to evaluate this .


diabetes mellitus for approximately 40 years .


he was reported to have had a myocardial infarction in the past ( ekg positive for ischemia , exercise tolerance test positive , cardiac catheterization positive , the patient is now status posta three-vessel coronary artery bypass graft in 1987 ) .

cardiac catheterization
ekg
exercise tolerance test


a small / moderate-sized , mild-intensity , reversible posterior lateral defect was also seen , indicative of mild / moderate ischemia .


the patient was on coumadin recently , ? whether for the arrhythmia .


an adenosine sestamibi was performed on 10/12/97 , which showed a negative electrocardiogram for ischemia and cardiac perfusion scans , with a moderate-sized , dense , fixed inferior defect indicative of scar .

an adenosine sestamibi
cardiac perfusion scans


the patient also hada history of arrhythmia , found approximately ten years ago , unknown what type .


incentive spirometry was started .


the patient was ruled out for a myocardial infarction , given his fall at the airport and bigeminy seen on electrocardiogram that he developed during conscious sedation during reduction of the fracture .

bigeminy
his fall
a myocardial infarction

reduction of the fracture
conscious sedation


his nph was recently increased today ( 10/23/97 ) to 24 units in the a.m. and 14 units in the p.m. with czi sliding-scale coverage .


oxygen 2-4 l to keep sa02 greater than or equal to 94-95% and wean as tolerated .


the patient is a 65-year-old male with a past medical history of diabetes mellitus , three-vessel coronary artery bypassgraft , congestive heart failure , who presents with a humeral fracture .

diabetes mellitus
congestive heart failure
a humeral fracture


the patient also needs a repeat endoscopy and a gi follow-up appointment inapproximately two months .


the patient was noted to be slightly hyponatremic over the past few days , with sodiums in the 128-132 range , but this was secondary to elevated glucose fingerstick blood sugars .


a second endoscopy was also performed several days later , in order to rule out a gastric ulcer , and also because the patient had had another episode of melena .


floxin 200 mg po bid was begun .


ekg :


two major fracture fragments were seen at the humeral head , articulating with the glenoid fossa .


it was thought that the blood in the esophagus was secondary to a possible mallory-weiss tear .

the blood in the esophagus
mallory-weiss tear


he can climb approximately three flights of stairs before becoming short of breath .


the patient is diffusely wheezy upon presentation .


postoperative changes of the sternum and media stinum were seen and no acute pulmonary disease was visualized .


righteye surgery for glaucoma in 05/97 .


the first was on 10/15/97 , which showed clotted blood in the esophagus .


chest x-ray 10/10/97 :


no slurred speech .


the patient has stable three-pillow orthopnea and occasional paroxysmal nocturnal dyspnea .

stable three-pillow orthopnea
occasional paroxysmal nocturnal dyspnea


guaiac negative .


nph insulin 24 units subq. q. a.m. nph insulin 14 units subq. q. p.m. czi sliding scale on a q. a.c. and q. h.s. fingerstick basis with the following scale :


he has a chronic cough with clear sputum .


the patient did not have chest pain until approximately 1-1/2 years ago , when he began to have chest tightness ( pressure ) approximately every three months with stress .

stress
chest tightness ( pressure )
chest pain


extraocular movements - conjugated eye movement intact .


after the patient 's procedure , he was felt to be volume overloaded .


the fracture was seen by orthopedics and was reduced .


cardiac monitor was placed on the patient , given the bigeminy , and he did rule out for myocardial infarction .


oropharynx moist , without lesions .


upper endoscopy x 2 were done .


however , his urine culture from the same day remained negative , and this was discontinued two days later .


the patient transfused 2 units on 10/20/97 for a hematocrit of 28.2.10 .


cardiology recommended that in addition to the medications already stated above , his hematocrit be kept greater than 30 .


the patient is retired , lives with his wife and one son , who is 47 years old and had multiple myeloma and renal failure .


the patient is alert and oriented and has a sling for his left humeral fracture .


a gastric ulcer was found and this was biopsied and pathology is pending at this time .


no fevers or chills , no chest pain , no shortness of breath .

chills
fevers
shortness of breath
chest pain


the patient has a severely comminuted fracture of the proximal left humerus .


physical therapy has been seeing the patient and putting him through passive external rotation to the neutral position of the left shoulder and forward flexion with physical therapy assistance .

passive external rotation
physical therapy assistance


1+ edema of the ankles , pulses present bilaterally .


mild right facial droop .


laser surgery for retinopathy .


he is status post a hemiarthroplasty on 10/17/97 .


normal sinus rhythm at 72 beats / minute , intraventricular conduction delay , q - waves seen in ii , iii , and avf with probable old inferior myocardial infarction .

old inferior myocardial infarction
intraventricular conduction delay


history of congestive heart failure , diagnosed approximately eight years ago .


the patient needs still better diabetes control .


he received ancef preoperatively .


the patient transfused 1 unit on 10/18/97 for a hematocrit of 29.4 .


the patient became slightly hypotensive on the night of 10/18/97 with systolic blood pressures in the 80s to 90s.


the patient has no chest pain when walking slowly and can walk approximately 1.5 miles .


the patient has been experiencing chronic , stable angina pectoris over the past one to one and a half years approximately once every three months .


the patient transfused 2 units of 10/16/97 for a hematocrit of 30.03 .


the patient transfused 1 unit on 10/19/97 for a hematocrit of 27.9 .


brittle bones were noted during the operation .


albuterol and atrovent nebulizers were done .


some type of cardiac arrhythmia , diagnosed approximately ten years ago .


no calf tenderness .


fournier 's gangrene versus necrotizing fasciitis .

fournier 's gangrene
necrotizing fasciitis


the patient is admitted for preoperative and orthopedic evaluations .


the patient presented to bri health in order to be evaluated for preoperative clearance .


no scapular fractures were present .


status post gastric stapling .


ventricular bigeminy was also seen .


glaucoma .


regular rate and rhythm , no murmur appreciated , normal s1 and s2 .


he also complained of occasional spells and jitteriness and some orthostatic dizziness and thus neurology was consulted and emg 's were performed which were normal .

occasional spells
some orthostatic dizziness
jitteriness


abdomen was obese with positive bowel sounds , nontender , nondistended .


occupational therapy became involved initially and he remained on patient controlled analgesia secondary to problems with left shoulder pain .


on admission revealed a white male with no palpable adenopathy .


the patient is a 52-year-old right handed male with a many year history of bilateral shoulder pain , right greater than left .


his hemoglobin a1c levels actually came back within normal limits , however , the wide excursions of his sugars were consistent with possible diabetes .


however , his course was otherwise complicated by discovery of persistently elevated blood sugars and endocrinology was consulted to rule out possible newly diagnosed diabetes .

persistently elevated blood sugars
newly diagnosed diabetes


his wound remained clean and dry and showed no signs of infection and healed well .


arthrogram in the distant past showed a right rotator cuff tear and he now has increased pain in his left shoulder .

increased pain in his left shoulder
a right rotator cuff tear


on admission included naprosyn .


the patient was admitted with the assessment of left rotator cuff repair and he was taken to the operating room on the day of admission where he underwent left rotator cuff repair under general endotracheal tube anesthesia .

left rotator cuff repair
general endotracheal tube anesthesia
left rotator cuff repair


thus , he was discharged on postoperative day number eight in good condition with a well healed left shoulder wound and doing well with occupational therapy with plans for him to follow-up with dr. necessary .


further work-up of his neurologic conditions were planned as an outpatient .


mri by report showed bilateral rotator cuff repairs and he was admitted for repair of the left rotator cuff .

repair of the left rotator cuff
bilateral rotator cuff repairs


on discharge included valium , 2 mg po t.i.d.; naprosyn , 500 mg po b.i.d. ________________________________ zv061/6138 ticena necessary , m.d. wo00


left rotator cuff tear .


he was placed on a diabetic diet and his sugars did show some improvement .


he has steroid injections in the right and in the left four times .


no known drug allergies .


lungs revealed occasional wheezing bilaterally at both bases .


heart was regular with a i / vi systolic ejection murmur without jugular venous distention .

a i / vi systolic ejection murmur
jugular venous distention


ankle surgery times two on the right .


heent exam was within normal limits .


examination of his shoulder revealed the patient to be able to flex his right arm to 170 degrees , internally rotate to 10 degrees and externally rotate to 40 degrees with positive joint tenderness .


it was not necessary to start him on oral hypoglycemics or insulin .


his neurologist was contacted , dr. cap , and the exact of his problems was not demonstrated during this hospitalization , however , they felt that this could possibly be an autonomic type neuropathy maybe secondary to some underlying diabetic process .

some underlying diabetic process
an autonomic type neuropathy


pilonidal cyst removal .


pulses were 2+ bilaterally .


there were no intraoperative complications .


back pain .


the patient is a 40 year old male with a history of prior anterior myocardial infarction and insulin dependent diabetes mellitus who was transferred from an outside hospital after an episode of acute shortness of breath and pulmonary edema .

acute shortness of breath
pulmonary edema
insulin dependent diabetes mellitus
prior anterior myocardial infarction


temperature 100.3 , heart rate 76 , blood pressure 100/78 , respiratory rate 16 , and an oxygen saturation of 96% on two liters .

temperature
respiratory rate
an oxygen saturation
heart rate
blood pressure


given his high right-sided filling pressure , he was started on lasix for diuresis and his captopril was increased for greater afterload reduction .

lasix
his captopril
greater afterload reduction
diuresis


the course had multiple complications requiring pressors .


he called the emt 's and was found to be in pulmonary edema by chest x-ray at centdick naco hospital medical center .


clear to auscultation with no wheezes or rales .


the patient was subsequently medically management after this hospitalization and has done very well .


it was felt that the patient should have an augmented medical regimen and as an outpatient undergo an exercise tolerance test with viability evaluation to determine whether he would benefit from revascularization .

viability evaluation
an exercise tolerance test

an augmented medical regimen
revascularization


no jugular venous distention .


pt 14.1 with an inr of 1.4 , ptt 36.7 .


2. prior history of anterior myocardial infarction


his coronary arteries revealed an 80% stenosis and a large om .


he was restarted on coumadin for his low ejection fraction and started on diuresis with iv lasix for two days and then switched to an oral lasix regimen .

coumadin
an oral lasix regimen
diuresis
iv lasix


at cardiac catheterization he had an ra pressure of 8 , an rv pressure of 52/10 , pa pressure of 60/25 , and wedge of 26 .

cardiac catheterization
an ra pressure
wedge
pa pressure
an rv pressure


he had a cardiac catheterization performed which revealed a three vessel coronary artery disease with an occluded rca , 70%-80% proximal lad , and a high grade left circumflex lesion after the om with distal left circumflex occlusion .


aspirin 325 mg p.o. q. day , capoten 25 mg p.o. q.8h. , nph insulin 28 units q.a.m. and 10 units q.p.m. , regular insulin 4 units q.a.m. and 4 units q.p.m. , simvastatin 20 mg p.o. q. day , digoxin 0.25 mg.

nph insulin
digoxin
capoten
simvastatin
regular insulin
aspirin


he had no chest pain , palpitations , diaphoresis , or nausea .

chest pain
palpitations
nausea
diaphoresis


chest x-ray showed no infiltrates and no pulmonary edema .


(3) in 1967 he had an orchiopexy for undescended testicle .


1. insulin dependent diabetes mellitus


insulin nph 10 units q.p.m. and 28 units q.a.m. , insulin regular 4 units q.a.m. and 4 units q.p.m. , aspirin 325 mg p.o. q. day , digoxin 0.25 mg p.o. q. day , simvastatin 20 mg p.o. q. day , captopril 37.5 mg p.o. t.i.d. , coumadin 5 mg p.o. q.h.s. , lasix 20 mg p.o. q. day .

coumadin
simvastatin
insulin nph
lasix
insulin regular
aspirin
captopril
digoxin


the patient has a history four years ago of being admitted to the etearal etsystems/ hospital after suffering an acute anterior myocardial infarction .


(4) coronary artery disease as above .


3. episode of pulmonary edema


it was felt that the patient possibly had a worsening of his coronary artery disease and therefore underwent cardiac catheterization on 01/17/96 .


he had flat t waves in i and avl , which were unchanged from previous ecg .


the patient also had an electrocardiogram in april of 1996 which was negative following , however was at a low workload .


his ecg showed no ischemic changes .


no known drug allergies .


he is to see dr. ench in two weeks to check his pt and inr , also to check for potassium .


he was diuresed and ruled out for myocardial infarction .


(1) insulin dependent diabetes mellitus x 15 years with no retinopathy or foot lesions .

retinopathy
foot lesions
insulin dependent diabetes mellitus


bun 25 and creatinine 1.4 .


his most recent echocardiogram in april of 1996 showed an ejection fraction of 20% with a thin fibrotic septum with akinesis and moderately severe hypokinesis in all other regions except for the lateral wall .

an ejection fraction
his most recent echocardiogram


electrocardiogram showed normal sinus rhythm at 63 with normal intervals .


white count 6 and hematocrit 41.5 .


it was felt that this cardiac catheterization was not significantly changed from his previous catheterization .

his previous catheterization
this cardiac catheterization


urinalysis was negative .


4. hypercholesterolemia


he also had a 50% lad stenosis , a 100% large dt stenosis and a nondominant rca with left rca collaterals .

a 50% lad stenosis
a 100% large dt stenosis


no edema with 2+ pulses .


the patient was admitted for further management of his pulmonary edema .


his mother and father both died secondary to myocardial infarction .


one of his brothers has had a myocardial infarction .


(2) bilateral cataracts .


the dominant left circumflex was occluded with left-to-left filling .


regular rate and rhythm with no extra heart sounds and no murmurs .


he was then transferred to the retelk county medical center for further management .


the patient 's was most recently admitted to centdick naco hospital medical center on martin luther king day after becoming acutely short of breath after a five minute walk .


having failed conservative management , the patient presented for elective right total hip replacement .

conservative management
elective right total hip replacement


there was no leg length discrepancy .


the patient 's pain has not been relieved by darvocet and advil .


it was his impression that the patient 's hypertension was controlled on hydrochlorothiazide .


the sodium was 140 , potassium 3.7 , chloride 96 , bicarbonate 30 , bun and creatinine 14/0.9 , glucose 105 , hematocrit 42 , white blood count 8.6 , platelet count 644,000 , prothrombin time 10.4 , partial thromboplastin time 28.7 , urinalysis trace white blood cells , slight occult red blood cells .

trace white blood cells
slight occult red blood cells

platelet count
prothrombin time
bicarbonate
bun
potassium
glucose
the sodium
creatinine
chloride
partial thromboplastin time
hematocrit
urinalysis
white blood count


the patient has no known drug allergies .


there she should received physical therapy to consist of a routine post total hip replacement rehabilitation protocol , with emphasis on gait training , partial weight bearing on the right lower extremity , using a walker or crutches .


the patient was an elderly woman in no acute distress .


the patient used the cane in her left hand .


hypertension , possible peptic ulcer disease 1959 , history of left ankle and knee fractures , 1980 .

left ankle and knee fractures
hypertension
peptic ulcer disease


her hematocrit remained stable in the low to mid 30 's and she did not require a transfusion .


recent urinary tract infection , e. coli 03/93 .


hydrochlorothiazide 50 mg. po qday , kayciel 40 meq. b.i.d. , ecotrin 1 tablet qday , ferrous sulfate 325 mg. po b.i.d. , folate 1 mg. po qday , multivitamins one tablet qday , tylenol # 3 1 to 2 po q3hours prn .

tylenol # 3
hydrochlorothiazide
ecotrin
ferrous sulfate
multivitamins
folate
kayciel


right hip osteoarthritis , status post right total hip replacement on 4/17/93 .


hydrochlorothiazide 50 mg. po qday , kayciel .


the patient was seen in consultation with the physical therapy service initially for routine rehabilitation after a total hip replacement .

routine rehabilitation
a total hip replacement


right hip 90 degrees of flexion , minus 30 degrees of extension , 20 degrees of abduction , 30 degrees of adduction , less than 5 degrees of internal rotation and flexion and less than 5 degrees of external rotation and flexion .

abduction
external rotation and flexion
extension
flexion
internal rotation and flexion
adduction


the patient is a generally healthy 85 year old female , who has had a five year history of right hip pain , worsening over the past several months .


recent herpes zoster .


radiographs demonstrate right hip osteoarthritis .


there were no acute ischemic changes .


the patient 's neurovascular examination was intact .


the patient 's coumadin was thus stopped and she was switched to bufferin .


cholecystectomy , total abdominal hysterectomy , cataract excision .

total abdominal hysterectomy
cataract excision
cholecystectomy


the chest x-ray showed borderline cardiomegaly but no acute cardiac or pulmonary disease .

acute cardiac or pulmonary disease
borderline cardiomegaly


her pain is located in the groin and thigh .


left hip 110 degrees of flexion , 0 degrees of extension , 30 degrees of abduction , 45 degrees of adduction , 10 degrees of internal rotation and flexion , 45 degrees of external rotation and flexion .

extension
external rotation and flexion
internal rotation and flexion
abduction
flexion
adduction


postoperative hypokalemia , resolved .


the electrocardiogram showed normal sinus rhythm at a rate of 80 with intraventricular conduction delay and poor r wave progression .

intraventricular conduction delay
poor r wave progression


her hemovac drains were removed on postoperative day # 2 as was her foley catheter .


the patient did have postoperatively hypokalemia to a level of 2.7 and subsequently was corrected with oral and intravenous potassium on 4/22/93 , the patient underwent a duplex ultrasound examination , which showed no evidence of of deep venous thrombosis .

deep venous thrombosis
postoperatively hypokalemia


medications on admission :


she uses a cane or walker for ambulation , and is limited to one to two blocks .


the head and neck exam was within normal limits .


regular rate and rhythm without murmur .


on the following morning 4/17/93 , the patient was taken to the operating room where she underwent a right total hip replacement , using a hybrid s-rom system .

a hybrid s-rom system
a right total hip replacement


given the patient 's low potassium level of 2.4 on the day of admission , he suggested supplementation with potassium .


right hip , osteoarthritis .


postoperative confusion , transient and resolved spontaneously .


the lungs were clear to auscultation .


it is associated with rest pain as well .


the patient should also have her potassium levels checked two times per week to insure that she is not becoming hypokalemic .


she has difficulty with shoes and socks and foot care .


hypertension .


otherwise you need to see a gynecologist to evaluate this bleeding .


pelvic ultrasound - normal ovaries , thickened endometrium hematocrit - 33


percocet as directed for pain


please return to the ed if you develop any worsening pain , vomiting or fevers > 101 .


dysfunctional uterine bleeding


vag bleeding


please follow up with gynecology - you will need to have your uterine bleeding evaluted


if you are unable to keep down liquids or have any fainting episodes we should see you again as well .


tylenol ( acetaminophen ) 650 mg po q4h prn pain colace ( docusate sodium ) 100 mg po bid prn constipation ibuprofen 600 mg po q4-6h prn pain milk of magnesia ( magnesium hydroxide ) 30 milliliters po qd prn constipation percocet 1-2 tab po q4h prn pain

pain pain pain constipation constipation


houghtbreun 6 weeks , no known allergies


insulin dependent gestational diabetic , prior c / s , rsap

insulin dependent gestational diabetic
prior c / s
rsap


attending evaluation


conditions , infections , complications , affecting treatment / stay iup at 36 weeks .


apgars 9,9


repeat c / s pps


responsible after study for causing admission ) iup at 36 weeks , delivered


weight :


7. anemia .


he is also to have ah for his home stent care .


this is a 70 year old gentleman with metastatic rectal cancer who presented with biliary obstruction .

biliary obstruction
metastatic rectal cancer


total bilirubin was 12 and direct bilirubin 8 .


the patient had two drains placed after a prolonged course and difficult procedure .

difficult procedure
a prolonged course
two drains


exam within normal limits .


white count was 8.2 , hematocrit 35 .


ast was 175 , alt 76 , ldh 454 .


the day prior , the patient had endoscopic retrograde cholangiopancreatography done with dilated ducts times two and eventually had interventional radiology attempt to place percutaneous drains to decompress his biliary tree .

percutaneous drains
interventional radiology


temperature was 99.1 , blood pressure 132/74 , heart rate 80 , respirations 18 , 02 sat 99% on room air .

02 sat
heart rate
temperature
blood pressure
respirations


the patient was taken back to surgery by the interventional radiology team and had a second drain placed without any difficulty and was transferred back to the short stay unit .


he was admitted to the short stay unit , given ancef and gentamicin per the team for antibiotic prophylaxis and observed overnight .


5. urinary tract infection .


the patient was admitted to the short stay unit for further evaluation .


the patient was an alert , jaundiced gentleman in no acute distress .


the patient was doing well with minimal to no belly pain and no nausea or vomiting .


cipro 500 mg p.o. b.i.d. , vasotec 10 mg q.d.


he will continue cipro p.o. for prophylaxis .


significant for colon carcinoma .


biliary obstruction


the patient was admitted to the short stay unit and continued to receive antibiotics overnight .


3. hypertension .


had a regular rate and rhythm with a ii / vi systolic murmur at the right sternal border .


were clear to auscultation .


2. metastatic colon carcinoma .


alkaline phosphatase was 372 .


was soft , nontender , with good bowel sounds .


the next morning , he was doing well with the intact drain draining bilious material without any difficulty .


were without edema .


6. cholangitis .


4. aortic stenosis with porcine valve .


he had midline catheter that was still in place and was draining bile .


in the past , he had biliary stents placed which clotted off .


the patient was observed overnight without any problems .


1. rectal carcinoma , status post partial colectomy .


after being transferred from the interventional radiology table to the stretcher , one of his lateral percutaneous drains had been pulled out inadvertently .


serum sodium 141 , potassium 4.0 , chloride 106 , c02 29.6 , calcium 9.2 , phosphorus 3.6 .

calcium
phosphorus
chloride
serum sodium
c02
potassium


a quantitative vq scan of the lung showed 42% ventilation to the left , 57% ventilation to the right , 42% perfusion to the left , 57% perfusion to the right .

perfusion to the right
ventilation to the right
ventilation to the left
perfusion to the left
a quantitative vq scan


history of gastrointestinal intolerance to tetracycline , erythromycin , declomycin associated with edema and rash , talwin associated with disorientation and gastrointestinal symptoms , dilantin has caused rash and edema , morphine associated with itching and gastrointestinal symptoms , demerol unclear .

disorientation
gastrointestinal intolerance
gastrointestinal symptoms
edema
rash
rash
edema
itching
gastrointestinal symptoms

demerol tetracycline erythromycin morphine declomycin dilantin talwin


white blood count 9.6 , hematocrit 38.8 , platelet 348,000 , mean corpuscular volume 85 and 86 , mch 29 , mchc 34 .

mch
hematocrit
mchc
mean corpuscular volume
platelet
white blood count