6. lasix 40 mg per day .


6. aerobid three puffs twice a day .


the patient 's major improvement came after the first two days with brisk diuresis with lasix .


1. atonic bladder with a suprapubic tube .


the patient was doing relatively at home until one day prior to admission he complained discomfort over a suprapubic catheter area .


the patient at that time noted slight shortness of breath but was sent home anyway .


3. coronary artery disease with a history of angina in the distant past .


neurological exam revealed an alert and oriented x 3 elderly male .


abdomen was soft , nontender with no masses palpable .


5. levaquin 500 mg per day to be continued until 4/12/99 .


he had a blood pressure 110/70 , heart rate 110 beats per minute and regular , respiratory rate 25 .

heart rate
respiratory rate
a blood pressure


3. ativan .5 mg twice a day .


neck exam revealed no jugular venous distention and no masses .


urine analysis showed 20-50 white blood cells and 3-5 red blood cells .

urine analysis
red blood cells
white blood cells


2. trusopt 1 gtt left eye three times a day .


sodium 148 , potassium 3.4 , glucose 174 , p02 102 , pc02 115 , ph 7.11 on 40% 02 .


4. nasal oxygen 3l per minute .


by the time the patient arrived at the oaksgekesser/ memorial hospital emergency room he was in moderate respiratory distress .


while in the oaksgekesser/ memorial hospital the patient on 4/4/99 complained of mild epigastric discomfort because he was put in cimetidine while in the intensive care unit for prophylaxis against peptic ulcer disease .

mild epigastric discomfort
peptic ulcer disease


atonic bladder with suprapubic catheter .


there were new air space opacifications in the left apex and the right lower lobe .


he was an elderly frail gentleman in moderate respiratory distress .


after one day in the medical intensive care unit the patient was stable enough to go to the floor where he continued the rest of his treatment .


deep tendon reflexes were symmetrical in all extremities .


the patient was brought to the emergency room one day prior to admission where he was evaluated by urology and had his catheter changed .


the patient was noted to be confused and to be disoriented toward the end of the day after complaining of shortness of breath for most of the day .

confused
shortness of breath
disoriented


respiratory failure .


rectal exam was unremarkable with stool heme negative .


anxiety .


on the day of admission the patient noticed increasing shortness of breath .


during that period of time he received nebulizer treatments with albuterol .


a chest x-ray in the oaksgekesser/ memorial hospital emergency room showed new changes on his chest x-ray on top of his usual severe bilateral emphysema_____ with scarring in both lungs .


as the patient 's diuresis continued his respiratory status improved .


lung exam revealed decreased breath sounds as well as crackles in the bases .

crackles in the bases
decreased breath sounds


2. heparin 5000 units subcutaneously twice a day .


the patient was upgraded to prilosec 20 mg per day for possible treatment of gastritis or gastroesophageal reflux disease .

gastroesophageal reflux disease
gastritis


he was in moderate respiratory distress .


2. anxiety .


they wanted the patient to return to his home after a stay at a rehab facility .


he also denies any chest pain .


his temperature was 98f .


this consisted of continued nebulizer treatments as well as intravenous antibiotics and intravenous solu-medrol .

nebulizer treatments
intravenous solu-medrol
intravenous antibiotics


4. brimonidine 1 gtt left eye three times a day .


associated medical problems include :


8. xalatan eyedrops 1 gtt in left eye per day .


3. xalatan 0.005% one gtt left eye qhs .


he was also started on intravenous ticarcillin for possible gram negative pneumonia .


it is hoped that when he is transferred to a rehab facility that he will continue with physical therapy to regain his strength and regain independence in activities of daily living .


1. albuterol 2.5 mg in 2.5 normal saline q4h .


he had a normal head , eyes , ears , nose and throat exam .


11. prilosec 20 mg per day .


severe chronic obstructive pulmonary disease .


10. trusopt 1gtt in left eye three times a day .


right lower lobe pneumonia .


it was felt that his respiratory status has been maximally treated by then .


9. alphagan 1 gtt in left eye three times a day .


continue current medication


noncardiac chest pain


the patient was given printed instructions for chest pain ( english ) .


labs stable , ntg sublingual , stress mibi was negative for ischemia .


return to the ed for worsening chest pain , shortness of breath , nausea / vomiting , fever / chills , weakness / dizziness/numbness , or any other problems .

nausea
worsening chest pain
any other problems
dizziness/numbness
vomiting
fever
weakness
chills
shortness of breath


cp


continuing taking meds she prescribed .


anxiety nos


psychological assessment , past medication responses discussed .


no new meds for now


atrovent neb qid , albuterol neb qid , ipratropium neb bid , flovent inh bid , serevent inh bid , and prednisone 30 qd taper .

ipratropium neb
albuterol neb
flovent inh
prednisone
serevent inh
atrovent neb


no n / v/ha / d no sweats , no chills , of abdominal pain , no chest pain , no pleuricy , no lee , no paresthesias , no numbness , no shoulder pain , no jaw pain .

pleuricy
v/ha
n
sweats
shoulder pain
paresthesias
d
lee
abdominal pain
chills
numbness
chest pain
jaw pain


niacin , vit .


heparin while having a demand ischemic episode


copd exacerbation with nstemi


copd ( s / p lung resection fev1 25% ) , chronic pericardial effusion , pvd , r renal artery stenosis , osteoporosis , presbylaryngis

osteoporosis
r renal artery stenosis
copd
pvd
chronic pericardial effusion
presbylaryngis


98.4 , 94 , 22 , 120/96 , 98% on 2l. nad , using scalenes , at / nc , no oral lesions , bibasilar rales otherwise clear , good air movement , rrr , no mrg , ntnd +bs , no cce , 2+ dps .


copd exacerpation with troponin leak likely nstemi secondary to demand ischemia .

troponin leak
copd exacerpation
demand ischemia
nstemi


please evaluate ambutlation ability and o2 requirement


salmeterol xinafoate and levofloxacin


steroid psychosis no benzos


likely exacerbation possibly from uri / pneumonia .


override added on 12/06/05 by belb , britherl , m.d. on order for zocor po ( ref # 33033281 )


override added on 12/07/05 by belb , britherl , m.d. on order for atorvastatin po ( ref # 33823759 )


please evaluate resolution of cardiac troponin leak and stable ekg .


mvi , cardiac diet


took prednisone 40 at home and presented to ed where found to have 1mm lateral st depressions and slight troponin and mb leak .

1mm lateral st depressions
slight troponin and mb leak


severe copd pneumonia recovering alcoholic recovering barbituate abuse unexplained hct drop poor appetite x 1 week

poor appetite
severe copd
unexplained hct drop
pneumonia


wbc 12.91


niacin , vit .


override added on 12/06/05 by belb , britherl , m.d. on order for levaquin po ( ref # 57095042 )


levaquin 500 qd empirically


cardiac enzymes trending down on 12.7.05 , anticoagulated while having leak .


responsible after study for causing admission ) copd exacerbation with nstemi


cardiac enzymes bid while actively having leak , asa


vitamin c ( ascorbic acid ) 1,000 mg po qd ecasa ( aspirin enteric coated ) 81 mg po qd calcium carbonate ( 500 mg elemental ca++ ) 500 mg po bid prednisone 20 mg po qam starting today ( 12/09 )


small pleural effusion , flat diaphrams no acute changes


attending evaluation


copd exacerbation


lisinopril 5 mg po qd


serevent diskus ( salmeterol diskus ) 1 puff inh bid


flovent ( fluticasone propionate ) 44 mcg inh bid starting today ( 12/09 ) levaquin ( levofloxacin ) 500 mg po qd

levaquin ( levofloxacin )
flovent ( fluticasone propionate )


likely having a nstemi secondary to demand .


aputum cultures pending .


4 days of worsening sob with sore throat and cough productive of yellow / green sputum .


administer iron products a minimum of 2 hours before or after a levofloxacin or ciprofloxacin dose dose

levofloxacin
ciprofloxacin
iron products


please evaluate resolution of copd exacerbation and need for any further antibiocis


potassium chloride and lisinopril


b-3 and atorvastatin calcium


i - heparin for ptt 50-70 durin enzyme leak . metoprolol 12 qid .


if on tube feeds , please cycle ( hold 1 hr before to 2 hr after )


taper over 2 weeks multivitamin therapeutic ( therapeutic multivi ... ) 5 milliliters po qd


salmeterol xinafoate and levofloxacin


r - monitor on telemetry


82f with copd exacerpation


please taper off your prednisone within 2 weeks


alendronate 70 mg po qweek


b-3 and simvastatin


take with 8 oz of plain water albuterol inhaler 2 puff inh qid starting today ( 12/09 ) atrovent inhaler ( ipratropium inhaler ) 2 puff inh qid starting today ( 12/09 )


echo -


fatigue secondary to worsening dyspnea .


nka admit diagnosis :


toprol xl ( metoprolol succinate extended release ) 25 mg po qd starting today ( 12/09 )


ppi prophylaxis


p - no evidence of failure


insulin , celexa , protonix , ambien and pancreas .


his hematocrit at the time of admission was 20.5 , after having been 32 one week earlier .


vital signs showed his blood pressure to be slightly decreased at 120/60 , pulse 64 , respirations 16 , temperature 98.8 , o2 sat 95 .

pulse
his blood pressure
vital signs
respirations
temperature
o2 sat


trace edema without cyanosis or clubbing .


he was treated with octreotide to try to slow down the bleeding .


back without cva or spinal tenderness .


significant for fatigue and increased abdominal discomfort .


despite all these measures , his bleeding was never totally controlled .


bowel sounds positive , soft , mildly tender in the epigastrium without hepatosplenomegaly , mass or tenderness .

mildly tender in the epigastrium
tenderness
mass
hepatosplenomegaly


evidence of anemia with being pale , but anicteric , no oral lesions .

oral lesions
evidence of anemia
being pale


his platelet count was maintained with platelet transfusion as necessary .


endoscopy showed multiple angio ectasias throughout the stomach .


the cause of death was a combination of gi bleeding felt to be ultimately related to his known metastatic pancreatic cancer .

death
his known metastatic pancreatic cancer
gi bleeding


he then had an angiogram with gel foam to try to control his gi bleed .


he received multiple treatments for this over the succeeding weeks .


the assessment was that he had a gi bleed .


at that point he had a change in mental status and was no longer responsive .

no longer responsive
a change in mental status


the patient has a known history of pancreatic adenocarcinoma .


he is admitted at this time because of significant gi bleeding .


r elbow injury


r elbow strain


xray - no evidence of effusion or fracture


do gentle range of motion exercises for the next few days .


the patient was given printed instructions for sprains , fractures and bruises ( english ) .


motrin 400-600 mg every 8 hours as needed for pain


it is recommended that you receive follow-up care with the department of orthopaedics if your symptoms are not improved in 5-7 days .


do no strenuous activity until your symptoms are improved .


use ice to sore areas for the next few days .


yesterday morning , he developed intermittent substernal chest pain with radiation to the left shoulder that worsened with any activity and any motion of his shoulders .

radiation to the left shoulder
intermittent substernal chest pain


they felt that there was obstruction and possible obstruction to airflow generating some obstructive apnea , as well as partial obstructive events .

obstruction
partial obstructive events
obstruction to airflow
some obstructive apnea


he was taken to the cardiac catheterization lab where cath showed top-normal lvedp at 12 ; no af ; widely patent rca stent ; mild cad in the left coronary artery symptom ; widely patent diagonal 1 at the site of prior ptca .


also , a long discussion was taken with the patient as most of his chest discomfort happens when he is quite anxious .


he has a history of hypertension , diabetes , and high cholesterol .


regular rate and rhythm ; s1-s2 ; positive s4 ; no murmur .


the patient was told that he should discus with his pcp further gi testing , as well as medications for anxiety .


he was transferred to the ro woodma healthcare for further cardiac care .


he also became short of breath with climbing a flight of stairs .


coronary artery disease ; hypertension ; hyperlipidemia ; sleep apnea ; diabetes type 2 .

hypertension
hyperlipidemia
coronary artery disease
diabetes type 2
sleep apnea


there was trace mitral regurgitation .


sodium 139 ; potassium 4.1 ; bun 15 ; creatinine 1.1 ; magnesium 1.6 ; sgpt 19 ; sgot 20 ; alkaline phosphatase 66 ; total bilirubin 0.6 ; direct bilirubin 0.2 ; total cholesterol 234 ; triglycerides 274 ; hdl 44 ; ldl 135 ; hemoglobin a1c 6.7 ; white cell count 6.1 ; hematocrit 36.4 ; platelet count 201 .

sgpt
direct bilirubin
total bilirubin
sgot
a1c
creatinine
alkaline phosphatase
potassium
hematocrit
magnesium
sodium
total cholesterol
triglycerides
platelet count
ldl
white cell count
hdl
bun
hemoglobin


in the er , he received 3 sublingual nitroglycerins and 1 mg of dilaudid .


the patient also complained of intermittent right neck swelling , and recommendations are to consider a ct scan with contrast to evaluate nodes in his neck .

nodes in his neck
intermittent right neck swelling


there was no evidence of pericardial effusion .


include lisinopril 5 mg p.o. every day ; nitroglycerin sublingual p.r.n.; toprol xl 100 mg p.o. every day ; plavix 75 mg p.o. every day ; avandia 4 mg p.o. every day ; lipitor 40 mg p.o. every day ; tricor 145 mg p.o. every day .

lisinopril
toprol xl
avandia
nitroglycerin sublingual
lipitor
tricor
plavix


the results of the pfts are unavailable at the time of this dictation .


apparently once his pain was free , his ekg was noted to have hyperacute t-wave anteriorly without progression .

hyperacute t-wave anteriorly
progression
his pain


in 2003 , he had a non st elevation mi , came to the rwh , and had a cath done , which showed a 40% rca , which was hazy .


tricor 145 mg p.o. every day .


his blood pressure was 114 to 123/62 .


diabetes ; hypertension ; hyperlipidemia .


since then , the patient has occasional chest pain with emotional stress , when he is angry or upset .


he was noted to have an episode of desaturation into the 80% range while sleeping .


he underwent lower extremity study to rule out a dvt in both legs .


pulmonary consult was done , and it was felt that the patient should undergo a formal sleep study , full pfts , and a repeat ct scan in 1 year to assess for pulmonary nodule that was seen .

a formal sleep study
pulmonary consult
a repeat ct scan
full pfts


on physical exam today , the patient did not have any swelling , and he states that he did not feel the swelling was present .


nitroglycerin 1 tablet sublingual q. 5 minutes x3 p.r.n. chest pain .


the patient was advised that he needs to speak with his pcp about medication for antianxiety and / or further testing or counseling to help control his anxiety level .


prior to discharge today , he underwent pfts .


the patient underwent a sleep study , the first part , which showed that he had 75 respiratory events observed with apnea , hypopnea index of 11 an hour .


they recommended that the patient may benefit from a trial of continuous positive pressure at the bedside .


soft , nontender , nondistended ; no guarding ; no masses ; positive bowel sounds x4 .


he then underwent a ct scan to rule out a pe .


temperature 97.9 .


he does have a lot of anxiety .


avandia 4 mg p.o. every day .


the mean heart rate was 68 .


he underwent a ptc stenting of an rca with a vision stent , 3 x 18 .


the patient underwent an adenosine stress test , where he exercised for 4 minutes , reaching 65% of predicted heart rate .


prilosec 20 mg p.o. every day .


the myocardial perfusion images show no definite evidence of ischemia .


diagonal 1 also had a 99% stenosis .


ativan 0.5 mg p.o. b.i.d. p.r.n. anxiety .


there was no evidence of mvp .


based on all the tests above , it was felt that the patient was stable for discharge home .


adenosine stress test .


the lv contractile function was normal .


the right ventricle was not dilated .


he also received lipitor 80 mg , plavix 300 , heparin iv , integrelin double bolus , followed by a drip .

lipitor
plavix
integrelin double bolus
heparin iv
a drip


coronary angiogram .


he did not have chest pain .


the patient ruled out for an mi with negative ck x4 and negative troponin x4 .


ekg was negative for ischemia .


chest x-ray .


he used ativan in the hospital , which helped him .


he received an angio-seal to the right common femoral artery .


the patient is a 55-year-old gentleman with a history of cad status post non st elevation mi in 11/17 who presents with chest pain x 48 hours .


chest ct .


there was trace aortic insufficiency .


he underwent an echocardiogram , which showed an ef of 60% .


however , please note that this nodule has been stable over time .


there was no other noted disease .


the patient will need to have a followup sleep study done as above per the recommendations based on the results .


during the hospital course , the patient was started on a ppi , nexium , for concerns of acid reflux .


there was no obvious segmental wall-motion abnormality .


right groin status post catheterization showed no hematoma or bruit .

bruit
hematoma
status post catheterization


however , his nitroglycerin was old and the script was expired .


aspirin 325 mg p.o. every day .


the patient has been scheduled to have the second part of the sleep study done on june 18 , 2006 , at 8:30 p.m. at rwh in the esley community hospital , 10th floor sleep lab , phone number 133-225-1257 .


the systolic function was within normal limits .


after that , he was pain-free .


there was no evidence of lv hypertrophy .


lower extremity pulses were intact without any edema .


heart rate 69 to 80 .


plavix 75 mg p.o. every day .


lung sounds clear bilaterally .


there was mild posterior vasal thinning .


there was no aortic stenosis .


part 1 of a sleep study .


he denies diaphoresis or nausea .


room air saturation 96% .


chest pain .


toprol xl 100 mg p.o. every day .


there was no evidence of la dilatation .


lopressor iv was given to control his heart rate .


lisinopril 5 mg p.o. every day .


an ivus was done , and it was felt that it was more severe .


he went to the padrugmoff hospital emergency room after trying nitroglycerin at home .


lipitor 40 mg p.o. every day .


the patient presented with a chief complaint of cp .


the patient 's preliminary admitting physician is kotedaizreke , lila and the preliminary admitting diagnosis is cp .


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


she had no murmurs and no gallops .


following balloon angioplasty , there was a local dissection with evidence of intraluminal thrombus , with a greater than 10% loss in the initial gain following coronary angioplasty .

a local dissection
coronary angioplasty
balloon angioplasty


in addition , on telemetry she developed complete heart block and hypotension requiring temporary pacing wire and then a permanent pacemaker implantation on 08-03-93 .

a permanent pacemaker implantation
temporary pacing wire


she developed congestive heart failure and required pressor support .


1. percutaneous transluminal coronary angioplasty and coronary atherectomy of the left anterior descending , 8-17-93 ,


2. relook coronary angiogram , 08-18-93 .


therefore , directional coronary atherectomy was performed with an excellent angiographic outcome , and a less than 10% residual narrowing .


the patient is a 58 year old female with a history of parkinson 's disease for more than twenty years who presented to the gemenadentoolpai medical center with a revolving anterolateral wall myocardial infarction on 08-01-93 .


the circumflex artery had a minor 40% stenosis .


her past medical history is remarkable for a history of parkinson 's disease .


her hospital course was remarkable for ruling in for a myocardial infarction with a peak cpk of 9,379 units with a 5.9% mb fraction .


ecotrin 1 tablet po qd , captopril 6.25 mg po tid , k-dur 20 meq. po qd , lasix 20 mg po qd , isordil 10 mg po tid , sinemet 1/2 tablet po bid , symmetrel 100 mg po bid , parloder 2.5mg po qd .

isordil k-dur ecotrin captopril sinemet symmetrel parloder lasix


her physical examination at the time of admission revealed a pleasant lady in no acute distress .


her electrocardiogram revealed normal sinus rhythm , left atrial enlargement , left axis deviation , poor r-wave progression in v1 through v4 , consistent with marked clockwise rotation , cannot rule out an old anteroseptal wall myocardial infarction .


the left ventricular ejection fraction was estimated to 38% .


the left anterior descending had a severe 80% proximal stenosis with a filling defect consistent with intraluminal thrombus .

intraluminal thrombus
a filling defect
a severe 80% proximal stenosis


she was maintained on intravenous heparin and was brought back to the cardiac catheterization laboratory on 08-18-93 for a relook coronary angiography .

a relook coronary angiography
the cardiac catheterization laboratory


coronary angiography demonstrated ongoing benefit of the initial coronary atherectomy .


specifically , there was no decrease in the initial gain that she achieved after directional atherectomy .


the examination of the extremities showed no edema .


her risk factors for coronary artery disease included a positive family history and an elevated cholesterol level .

a positive family history
coronary artery disease
an elevated cholesterol level
her risk factors


the examination the abdomen was benign .


the main left coronary artery had a 20% stenosis .


she has been under the care of dr. aalv manual and was referred here for further therapy .


the jugular venous pressure was elevated at 6 cm above the sternal angle .


cine left ventriculogram revealed a dilated left ventricle with an area of anterolateral , apical , and septal akinesis .


she underwent cardiac catheterization on 8-15-93 and was found to have a left ventricular end diastolic pressure of 28 millimeters of mercury .


she was transferred in stable condition to the pasi for further rehabilitation therapy .


acute myocardial infarction .


there were non-specific st-t wave abnormalities .


the patient was maintained on intravenous heparin .


her electrocardiogram showed a new right bundle branch block and left anterior hemiblock .

a new right bundle branch block
left anterior hemiblock


1. coronary artery disease ,


there were prominent q-waves in avl , consistent with lateral myocardial infarction .

lateral myocardial infarction
prominent q-waves in avl


she had a dominant right coronary artery with minor disease .

a dominant right coronary artery
minor disease


the blood pressure was 120/70 millimeters of mercury .


on 8-17-93 , she was taken to the cardiac catheterization laboratory where she underwent percutaneous transluminal coronary angioplasty of the proximal left anterior descending .


the patient was seen in consultation by the neurology department because of the history of parkinson 's disease .


the patient was transferred to the heaonboburg linpack grant medical center for consideration of coronary angioplasty .


her pulse was regular at 80 beats per minute .


the cardiac examination revealed anapical impulse in the fifth left intercostal space , left to mid clavicular line .


2. unstable angina ( postmyocardial infarction angina ) ,


she had no prior significant cardiac history and presented to her local medical doctor 's office with an episode of severe retrosternal chest pain .


3. parkinson 's disease .


the patient tolerated the procedure well .


he was noted to be in rapid af on several episodes receiving 5 mg iv lopressor each time with improvement .


rectal normal tone , guaiac positive brown stool , no perirectal lesions or erythema .

guaiac positive brown stool
perirectal lesions
erythema


blood cultures drawn at the outside hospital grew out pseudomonas that was sensitive to imipenem and tobramycin .


the plan is to continue the digoxin and to recheck an echocardiogram to assess his ejection fraction when he is clinically better .


however , with increasing diuresis and improving septic pictures his o2 saturations have improved and he is now on nasal cannula and will be maintained on nasal cannula to keep his sat above 93% .

increasing diuresis
nasal cannula
nasal cannula


he was treated initially with ceftazidime and gentamicin but there was a question about the organism 's susceptibility from lab studies done at the outside hospital .


pt 17.6 , ptt 48.7 , fibrinogen 686 , tt 39.2 .


he has been maintained on tube feeds and that should be continued .


the patient is being maintained on digoxin for his paroxysmal atrial fibrillation .


an mri was performed upon admission and showed an epidural mass at the right posterior lateral t9 to t12 area invading the neural foramina .


a workup done in de is not available at the time of this dictation .


he was given stress steroids and was subsequently transferred to lorough medical center 's intensive care unit for further management .


7) thrombocytopenia status post bone marrow transplant .


tylenol 650 mg po q4h p.r.n. , dulcolax 10 mg per rectum b.i.d. p.r.n. , decadron 5 mg iv q6h , digoxin 0.25 mg po q day , colace 100 mg po t.i.d. , florinef 0.1 mg po q day for presumed adrenal insufficiency , imipenem 500 mg iv q6h , insulin nph 60 units subcu q a.m. , insulin nph 20 units subcu q p.m. , insulin czi sliding scale regular , synthroid 125 mcg po q day , magnesium sliding scale , potassium sliding scale today , morphine sulfate iv p.r.n. dressing changes and breakthrough pain , carafate 1 gm po q.i.d. , tobramycin 200 mg iv q30h , vancomyin 1 mg iv q18h.

colace
magnesium sliding scale
imipenem
potassium sliding scale
morphine sulfate iv
synthroid
florinef
dulcolax
digoxin
insulin czi sliding scale regular
tylenol
tobramycin
decadron
dressing changes
carafate
insulin nph
vancomyin
insulin nph


abdomen non-distended , positive bowel sounds , soft , non-tender , no hepatosplenomegaly or masses .

non-distended hepatosplenomegaly non-tender masses


positive for diabetes mellitus .


his pt and ptt are now normal , however , he continues to run a low platelet count .


he was subsequently switched to imipenem and tobramycin and was maintained on those medications throughout the hospital course .


he has been on increasing doses of insulin receiving nph in the morning and night in addition to a czi sliding scale on a q6h basis .

nph
increasing doses of insulin
a czi sliding scale


chest clear to auscultation with a few fine crackles at the left base .


the organism grown at this institution was sensitive to imipenem , ceftazidime , amikacin , gentamicin , ciprofloxacin , tobramycin but was resistant to cefotetan , ceftriaxone , mezlocillin , bactrim , ampicillin , chloramphenicol , and sulbactam .

cefotetan ceftriaxone ciprofloxacin gentamicin mezlocillin imipenem tobramycin ceftazidime ampicillin chloramphenicol sulbactam bactrim amikacin


on transfer include vancomycin , ceftazidime , gentamicin , solu cortef 100 mg q8h , lasix , synthroid , insulin , ms contin 60 mg b.i.d. , mso4 2 mg p.r.n. pain iv , dopamine 12 mcg per minute .

lasix
gentamicin
solu cortef
vancomycin
synthroid
ceftazidime
ms contin
mso4
insulin
dopamine


there were cultures obtained seeping from the wound at retelk county medical center and those also grew out pseudomonas aeruginosa .


this bone marrow transplant did not produce remission and then he was treated with three cycles of vad subsequently .

this bone marrow transplant
three cycles of vad


he also complained of some fecal incontinence the day prior to admission without urinary incontinence .

some fecal incontinence
urinary incontinence


he initially required a face mask to keep his saturation above 90% .


5) plasmacytoma .


at the time of presentation the patient denied headache , arm weakness , changes in vision , dysarthria , abdominal pain , nausea or vomiting , chest pain or shortness of breath .

dysarthria
chest pain
nausea
headache
vomiting
arm weakness
changes in vision
abdominal pain
shortness of breath


the plan is to continue the supplemental insulin while he is on steroids and while his sugars remain high .


neurological exam on admission revealed he was drowsy but easily arousable to voice , oriented to person , retelk county medical center , and date , able to say no but mildly inattentive during examination .

examination
neurological exam on admission


chest x-ray was without infiltrates , wand in good position .


however , one day prior to admission the patient developed right lower extremity pain and could not walk secondary to the pain .


there was evidence of cord compression .


neck supple , carotids without bruits .


he has had no significant episode of tachycardia or blood pressure alteration during the final days of hospitalization .


1) multiple myeloma .


he was treated with ceftazidime , gentamicin , and vancomycin and also was started on a dopamine drip for treatment of his sepsis .

gentamicin
ceftazidime
a dopamine drip
vancomycin


a swan was placed and initial readings were cvp of 6 , wedge pressure of 10 to 12 , cardiac index of 4.7 , and svr of 438 all consistent with a pseudomonas sepsis picture .

cardiac index
wedge pressure
a swan
cvp
svr


the plan is to complete a full course of imipenem and tobramycin for his pseudomonas cellulitis .


according to her scanty records , an mri of the spine showed diffuse spinal column involvement with lesions in t4 and t8 with no cord compression at that time .

diffuse spinal column involvement
lesions in t4 and t8
cord compression


his decadron dose was titrated down to 5 mg iv q6h on 12/3/94 .


the tobramycin and imipenem were started on 11/25/94 .


of note , the patient has extreme pain with these dressing changes and requires parenteral morphine sulfate for pain control during dressing changes .

extreme pain
pain control during dressing changes

these dressing changes
parenteral morphine sulfate


cardiac exam was regular s1 and s2 , no murmur .


5) chronically low platelet count .


as mentioned above he has a cord compression and is on steroids .


he should also be encouraged to eat as much as possible orally in addition to this tube feeds and aspiration precaution should be maintained .


in 08/94 , the patient developed lower back pain .


about two weeks prior to admission the patient developed mid back pain , burning in nature with radiation around the right lower ribs .


over the next 12 hours while in transit to the hospital , the patient 's right lower extremity became red , swollen , and increasingly painful .


an mri without gadolinium done on 11/20/94 of the spine showed a right posterior lateral epidural mass extending from t9 to t12 .


2) paroxysmal atrial fibrillation .


the plan is to complete a full course of xrt to the spinal region for the plasmacytoma .


1) right lower extremity pseudomonas cellulitis .


the patient 's decadron dose was increased to 12 mg q day and he was also started on ms contin and radiation therapy was being planned and arranged at the petersly hospital and medical center .

ms contin
radiation therapy
the patient 's decadron dose


he can be given intravenous lasix as needed for any evidence of respiratory compromise or increasing pulmonary edema .

respiratory compromise
increasing pulmonary edema


he was then treated with radiation therapy from t3 to t9 receiving 2500 cgy from 08/94 to 09/94 .


these findings were consistent with the cord compression .


the patient 's clinical situation was most consistent with a pseudomonas cellulitis and subsequent sepsis .

the patient 's clinical situation
a pseudomonas cellulitis
subsequent sepsis


deep tendon reflexes were 2+ in the upper extremities , 1+ in the patella reflexes , no reflexes at the ankles , upgoing babinski toes bilaterally .


blood cultures , urine culture , and ua were all done .


he was taken to huyychestleme health of in scoo , utah where he had a temperature of 99.9 , blood pressure 90/50 , heart rate 128 , and o2 sat of 91% on room air .

a temperature
heart rate
blood pressure
o2 sat


these dressing changes are applied by applying the xeroform on betadine initially and then changing it with sterile dry bandages .

xeroform
these dressing changes
sterile dry bandages
betadine


blood cultures drawn on admission subsequently grew pseudomonas aeruginosa .


the patient 's lesion compressing his thoracic spine was never biopsied , however , the mri appearance does not seem to be infectious and is most consistent with plasmacytoma for which he is receiving the radiation therapy .

infectious
the patient 's lesion
plasmacytoma


his neurological exam remained stable with no evidence of increasing lower extremity edema .


he has had chronic bilateral lower extremity swelling since his transplant but the right lower extremity swelling was noticeably increased .


motor exam normal tone , positive asterixis , no drift .


an echocardiogram performed at the outside hospital while he was septic showed decreased global ef .


there was no csf density .


the patient has a poor nutritional status with hypoalbuminemia .

hypoalbuminemia
a poor nutritional status


he has been in and out of atrial fibrillation and normal sinus rhythm .


his decadron dose will be slowly titrated down over time following his neurological exam closely .


both of these responded to three day course of vitamin k 10 mg each day .


he is being maintained with twice daily xeroform with betadine changes .


heent exam atraumatic , no oral lesions .


thrombocytopenic inducing drugs should be avoided if possible on this patient .


extremities reveal the right lower extremity was tense , purple-red , swollen , and was warm from the knee to the ankle and extremely tender .

swollen
extremely tender
tense
purple-red


he was evaluated by the surgery department and it is there feeling that there is no indication for surgical intervention / amputation at this time .


there was pitting edema of both lower extremities but no evidence of cellulitis of the left lower extremity .

pitting edema of both lower extremities
cellulitis of the left lower extremity


this has been evident since the time of his bone marrow transplant .


he also received several blood transfusions while here to maintain his hct around 30 .


the patient has had multiple myeloma since 1990 .


3) plasmacytoma of t9 through t12 .


ua showed no white blood cells , positive granular casts .


vancomycin was also added to his regimen on 11/28/94 and this was primarily to provide improved mrsa coverage as he continued to have erythema along the lateral right lower extremity .

his regimen
improved mrsa coverage
vancomycin


2) paroxysmal atrial fibrillation .


on admission revealed white blood cell count 4.2 , hct 27 , platelet count 28 .

hct
white blood cell count
platelet count


8) elevated pt and ptt :


the patient was initially treated with dopamine which was subsequently weaned off after his sepsis improved .


6) failed autologous bone marrow transplant in 10/92 .


8) multiple myeloma .


we have been transfusing him with platelets to keep his counts above 20,000 to reduce his bleeding risk .


he was initially treated with iv decadron 10 mg up front and then 6 mg q6h.


in addition , the patient received a five day course of intravenous igg to improve infection control .


6) poor nutritional status .


he underwent an autologous bone marrow transplant in 10/92 at petersly hospital and medical center .


glucose 191 .


question of penicillin and sulfa drugs leading to a rash .


3) cord compression .


he also began to develop noticeably increasing bilateral lower extremity weakness and possibly numbness in the lower extremities .


on admission showed a non-toxic appearing male with temperature 99.5 , blood pressure 82/50 , heart rate 118 , respiratory rate 15 .

respiratory rate
heart rate
blood pressure
temperature


7) hypothyroidism .


he has been receiving radiation therapy to that area during the hospital stay .


the patient has steroid induced diabetes mellitus .


as mentioned earlier he continues to have erythema tracking up his leg and up to his lateral thigh .


the cause of this erythema is not know at this time but has not shown extensive progression .


4) chronic renal insufficiency .


he stated that he had difficulty rising from a chair .


he has been on decadron since 08/94 .


at that time he received total body irradiation of 1400 cgy .


the patient has a plasmacytoma affecting the spine .


magnesium 1.7 .


4) steroid induced diabetes mellitus .


during this hospitalization , pt was noted to have sinus bradycardia and pauses , associated with desaturations in the 70 's .

pauses
sinus bradycardia
desaturations in the 70 's


he will have outpt fitting at the sleep center in sabo .


simvastatin and niacin , vit. b-3


wellbutrin ( bupropion hcl ) 150 mg po bid folate ( folic acid ) 1 mg po qd ativan ( lorazepam ) 1 mg po q12h x 1 days ativan ( lorazepam ) 1 mg po qhs x 7 days starting on 11/5 mvi therapeutic w / minerals ( therap vits / minerals ) 1 tab po qd


ett was negative for ischemia .


echo showed ef 45-50% , with mild dilatation and no significant valvular disease , and nl pap .

mild dilatation
significant valvular disease


fh , htn , tobacco .


presented w / epigastric pain , sob at work .


simvastatin and niacin , vit.


responsible after study for causing admission ) obstructive sleep apnea


conditions , infections , complications , affecting treatment / stay htn tobacco etoh abuse sinus bradycardia


cpap at 5 was attempted , but pt did not tolerate this .


indicated lisinopril 10 mg po qd nicotine patch ( nicotine ) 21 mg/day tp q24h


firmert hospital 11/6 at 9am scheduled , cialneinsisters hospital and medical center 11/16 at 8:15pm scheduled , dr. condnort 12/04 at 2pm scheduled , dr. lila spielbjaque 12/01 at 1:50pm scheduled , no known allergies


indicated thiamine ( thiamine hcl ) 100 mg po qd simvastatin 40 mg po qhs


50 yo m from taheimpromong admitted w / cp for r / o mi .


r / o mi


has significant cardiac


override added on 11/03/00 by twada , stasterl etheshi , m.d. on order for mvi therapeutic w / minerals po ( ref # 90299469 )


b-3 reason for override :


obstructive sleep apnea


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


headache


md evaluation , head ct


migraines for 10 days


following evaluation and treatment , the patient 's disposition at the end of the visit was admitted as an inpatient to oaksgekesser/ memorial hospital .


the patient 's preliminary admitting physician is brittsfyfeast , sher t and the preliminary diagnosis is s / sob .


the patient presented with a chief complaint of sob .


override added on 10/01/03 by kotejoasthoreuphkays , gai , m.d. on order for tylenol po 650 mg q4h ( ref # 85225311 )


tylenol ( acetaminophen ) 650 mg po q4h prn pain


breech , multiple gestation ,


undelivered


take with food milk of magnesia ( magnesium hydroxide ) 30 milliliters po bid prn constipation percocet 1-2 tab po q4h prn pain


weight :


sulfa , bactrim


acetaminophen and acetaminophen


no observed abnormalities


pregnancy


apgars 8,9


colace ( docusate sodium ) 100 mg po bid ibuprofen 600 mg po q4h prn pain


apgars 8,8


temperature 97.4 , heart rate 100 , blood pressure 142/89 , and o2 saturation 94% on room air .

heart rate
temperature
blood pressure
o2 saturation


chest ct showed bibasilar diffuse infiltrates , pcp was negative .


sinus tachycardia at 100 .


no nausea , vomiting , or diarrhea .


the patient 's differential diagnosis included initially a question of an atypical pneumonia or pcp .


he did drink alcohol three drinks per day , no withdrawal symptoms .


he denied any fevers , chills , or night sweats .


2. bactrim double strength one tablet p.o. q.d. for pcp prophylaxis during his steroid course .

bactrim double strength
pcp prophylaxis
his steroid course


pneumonia


chest exam reveals coarse rhonchi with some bibasilar crackles .


he was continued on azithromycin and cefuroxime until bronchoscopy results were known , negative .


echocardiogram was checked to rule out chf , showed lvh and trace tr , ejection fraction of 60% without any pulmonary hypertension .


neuro exam was alert and oriented x 3 .


thus initially he had been started on prednisone and bactrim , this was discontinued .


in emergency room , he was noted to be afebrile with stable vital signs , was treated with iv fluids , azithromycin , and cefuroxime .


he did note some weight loss over the past several months , though the amount was unknown .


multiple conversations were had with the patient as well as an interpreter stating the importance of not smoking and keeping flames away from his oxygen tank .


sister with bone cancer .


ambulatory saturation was 82% on room air .


pulmonary consult was invited , initially the patient refused bronchoscopy , however , did agree to it during his hospital stay .


white blood cell count 11.2 , hematocrit 43.2 , and platelets 447,000 .

platelets
hematocrit
white blood cell count


abdominal exam revealed soft , nontender , and nondistended abdomen .


the patient was in his usual state of health until two months prior to admission when he began to notice shortness of breath on climbing flights of stairs .


the results were negative for micro , most likely diagnosis as per review of pathology is organizing pneumonia with possible diagnosis of boop and chronic inhalational injury was a possibility .

chronic inhalational injury
organizing pneumonia
boop
micro


he stated that this became worse over the last month until he was noted to be short of breath at rest .


his electrolytes were repeated p.r.n.


his extremities were without cyanosis , clubbing , or edema .


his ppd has been negative one year prior to admission , ppd was rechecked during this admission and was negative .


he was ruled out for tuberculosis with an induced sputum x 3 , which showed no afb .


there is no hepatosplenomegaly noted on abdominal exam .


the patient required supplemental oxygen to keep his oxygen saturation greater than 93% .


sodium 139 , potassium 3.5 , chloride 103 , bicarbonate 25 , bun 9 , creatinine 0.9 , and glucose 83 .

chloride bun creatinine bicarbonate potassium glucose sodium


his skin was clear , without rashes .


no known drug allergies .


the patient was discharged to home in satisfactory condition with home oxygen .


1. prednisone 60 mg p.o. q.a.m.


he was told to call a doctor or come to the emergency room should he have any further troubles , breathing , chest pain , or fevers .


the patient is a 38-year-old gentleman , spanish-speaking , from the taheimpromong , with no significant past medical history , who presents with shortness of breath x 2 months as well as a dry cough x 1 month .


heent exam revealed sclerae to be injected .


shortness of breath .


he also states that he has had a dry and nonproductive cough for one month .


he initially had refused hiv testing , however , was finally consented , hiv was noted to be negative .


heart exam was regular rate and rhythm , tachycardic , with a flat jugular venous pressure .

a flat jugular venous pressure
tachycardic


he was treated with supportive medical therapy for his cough .


general exam revealed a well-developed , well-nourished gentleman in no acute distress .


no lymphadenopathy was noted in the neck , there was a question of right axillary lymphadenopathy .

right axillary lymphadenopathy
lymphadenopathy


he was sent home with ldamc services to help with his medications as well as oxygen education .


diffuse interstitial process / consolidation .

consolidation
diffuse interstitial process


lovenox .


hepatitis serologies were negative .


the patient presented with a chief complaint of cp sob .


the patient 's preliminary admitting physician is dreissneigh , liru and the preliminary admitting diagnosis is cp , r / o mi .


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


pelvic exam


perianal and perivaginal pruritis


if tests are positive , follow up with your primary care doctor of gynecologist .


please call ( 994 ) 944-4238 in 2-3 days to obtain results of the lab tests that were ordered .


r / o hemmoroids


per the patient 's wishes , she was transferred to the windgo hospital for chemotherapy .


there was no lymphadenopathy .


a specimen was obtained by fine needle aspiration and the pathology of this was consistent with adenocarcinoma .


calcium 9.1 .


the patient had an elective termination of her pregnancy on 1/13/91 .


ahead ct scan revealed a metastatic lesion in the right vertex of the calvarium but no intracranial abnormalities .

a metastatic lesion
intracranial abnormalities


her ldh was 394 .


cardiac exam was tachycardic and regular , normal s1 and s2 .


a fine needle aspirate of this mass reportedly revealed giant cell tumor .


on 12/23 , she was seen by dr. stonge at bri health where a 3 x 7 cm left mid clavicular mass was noted .


her alkaline phosphatase was 1514 .


the patient 's low serum albumin is also contributing to her extensive edema .

the patient 's low serum albumin
her extensive edema


total bilirubin 3.0 , direct bilirubin of 2.0 .


heent exam was unremarkable .


the abdominal and pelvic ct scans showed no suspicious gi masses , no pancreatic mass ; a 2 cm ovarian cyst .

pancreatic mass
suspicious gi masses
a 2 cm ovarian cyst


serum markers were normal .


impending spinal cord compression .


the pathology , unfortunately , revealed an aggressive adenocarcinoma ( micropapillary type ; mucin producing ) .


total bilirubin was 2.1 .


the poor prognosis for the patient and child were discussed and after the patient decided to have an elective abortion , an abdominal ct scan was obtained which revealed diffuse metastatic lesions of the liverspine , ribs and most of the lymph nodes .


subsequently , the mass progressively increased in size and the patient had developed significant discomfort in this region .

significant discomfort in this region
the mass


an abdominal and pelvic ct scan with iv contrast revealed bilateral pulmonary nodules and bilateral pleural effusions , extensive liver metastases , narrowing of the intra hepatic ivc and distention of the azygous system suggestive of ivc obstruction by liver metastases ; ascites ; multiple bony metastases ; and an isolated splenic metastases .

an isolated splenic metastases
bilateral pulmonary nodules
narrowing of the intra hepatic ivc
multiple bony metastases
distention of the azygous system
ivc obstruction
liver metastases
bilateral pleural effusions
extensive liver metastases
ascites


the review of the pathology from bri health confirmed a high grade adenocarcinoma .


the ca-125 was still pending and alphafeto protein is still pending .


she received three days of intravenous etidronate with normal saline diuresis and the serum calcium subsequently decreased to 9.0 .

normal saline diuresis
intravenous etidronate


the mri scan on admission revealed an impending cord compression at the level of t10 .


on admission included percocet for pain and multivitamins .


the work-up for the extent of the patient 's disease included mri scan of the cervical and thoracic spine which revealed multiple metastatic lesions in the vertebral bodies ; a t3 lesion extending from the body to the right neural for amina with foraminal obstruction .


the patient was initially told that this was a benign tumor and that it could simply be watched and definitively treated after the delivery of her baby .


hypercalcemia :


lungs were clear to auscultation .


the patient was then switched to po etidronate .


it was felt that the patient 's extensive pulmonary metastases and bilateral pleural effusions resulted in increased work of respiration and a sensation of shortness of breath .


the patient has extensive hepatic metastases and by ct scan there is obstruction of the intrahepatic ivc .

obstruction of the intrahepatic ivc
extensive hepatic metastases


the hcg on admission was 30,710 and on 1/19 was 805 .


ptt was 27.3 .


ast was 89 .


sensation was intact to light touch .


the patient 's father died at age 69 with metastatic prostate cancer .


on admission included an alt of 108 , ast of 286 .


this prompted further staging work-up .


she denied fevers , chills or sweats .


she has not had any alcoholic beverages during this pregnancy .


there were no rales or wheezes .


skin exam revealed a right posterior parietal scalp nodle measuring 2 x 3 cm which was very firm .


there was no obvious gior pancreatic tumor identified .


at the time of discharge , the patient 's electrolytes were within normal limits .


the patient subsequently had a limited chest ct at bri health which showed diffuse bilateral pulmonary metastases , metastases to the sternum , rib , multiple spinal levels ; internal mammary lymphadenopathy .


the patient 's sister has a history of cervical cancer .


it was decided to have the patient 's medical and oncological issues managed at windgo hospital .


blood pressure was 98/64 .


the patient had a very firm nodule at the vertex of her calvarium .


on discharge included etidronate , 475 mg iv q day ; heparin , 5000 units subcutaneously b.i.d. ; decadron , 4 mg po q six hours ; ms contin , 45 mg po b.i.d. ; pepcid , 20 mg po b.i.d. ; senekot , one tablet po t.i.d. ; bronkosol , 0.25 cc q four hours .

decadron
etidronate
bronkosol
heparin
ms contin
pepcid
senekot


hypercalcemia .


although the patient 's room air saturation was 96% during this admission , she subjectively complained of increased shortness of breath .


the patient had back pain on admission without any focal neurological signs .


she has had no motor weakness , abnormal sensation , numbness , tingling or incontinence of bowel or bladder .

incontinence of bowel or bladder
abnormal sensation
tingling
motor weakness
numbness


the cea was less than 0.7 .


the patient presented with a serum calcium of 11.8 and an albumin of 2.3 on admission .


there was mild lower thoracic tenderness .


there was no jugular venous distention .


the patient was transferred to nimaconwood valley hospital for management of her cancer and termination of the pregnancy .


work-up for the source of the primary tumor which is still unknown included a mammogram which identified no suspicious microcalcifications and no dominant masses .

dominant masses
the primary tumor
suspicious microcalcifications


there was a 1 cm firm nodule in the right upper quadrant of the abdomen .


on 1/5 , the patient underwent a local tumor debulking at bri health under local anesthesia .

local anesthesia
a local tumor debulking


she was started on decadron and on 1/17 began the first of ten radiation treatments to two fields ( t2 to t5 and t9 to t11 ) .


over the past four weeks , the patient reported progressive shortness of breath and mid thoracic back pain .

mid thoracic back pain
progressive shortness of breath


the abdomen was tympanitic and nontender .


pt was 12.9 .


back was without cva tenderness .


the liver was 11 cm by percussion .


there was no scapular tenderness .


per the patient 's wishes , dr. dalywoo droreite the windgo hospital was consulted for a second opinion regarding the management of her malignancy .


pulse 82 .


there was a ii / vi systolic ejection murmur loudest at the left upper sternal border .


hypoxia and shortness of breath :


there was a 1 cm firm nodule at the left upper thoracic region of the back between the midline and the scapula .


hematocrit was 30.6 .


impending spinal cord compression :


white blood cell count was 16.89 .


intrauterine pregnancy at 23 weeks .


dr. linke recommended chemotherapy with pfl .


direct bilirubin was 1.4 .


extremities revealed 1+ bipedal edema on admission .


neurological examination revealed the patient to be alert and oriented times three .


the patient is a 34-year-old female with a 22 week intrauterine pregnancy who was transferred from bri health with diffuse metastatic adenocarcinoma of unknown primary .


erica and basic cystic protein stains are still pending .


respiratory rate 20 .


metastatic adenocarcinoma of unknown primary .


this has resulted in marked bilateral lower extremity and presacral edema with ascites .


calcium 11.8 .


subsequently , the mass continued to increase in size .


hematocrit was 32.5 .


an epidural mass was present at t10 which was extending from the lamina or spinous process anteriorly and almost compressing the spinal cord .


alkaline phosphatase 1148 .


alt was 53 .


ldh 806 .


deep tendon reflexes were 1-2+ and symmetric bilaterally .


the patient was in her usual state of excellent health until july of 1991 when she first noted a left clavicular mass .


there was no egophony .


ptt was 29.8 .


a bone scan revealed increased uptake in the left chest wall , left anterior ribs four to six , and increased uptake in the left and right lateral skull in the area of the parotids .


pt was 13.2 .


there was no heave .


white blood cell count was 11.14 .


inferior vena cava obstruction .


there has been no gi or gu symptoms except for constipation .


ivc obstruction :


no known drug allergies .


abdomen was gravid .


albumin was 2.3 .


albumin 2.3 .


pelvic exam revealed normal vulva , vagina normal , cervix normal , uterus anteverted , small , nontender .


no masses or tenderness .


130/82 and heart rate 80 .


clear to auscultation and percussion bilaterally .


she did well and was admitted to the gyn service postoperatively because the patient had persistent pain .


1. undesired fertility .


she was extensively counseled regarding other methods of birth control and desired to proceed with definitive surgical therapy .

birth control
definitive surgical therapy


the patient then underwent liposuction of her abdomen , inner thighs , hips , flanks , chest and arms with dr. chain .


the patient is a 30 -year-old gravida iii , para ii who presented desiring definitive surgical sterilization .


blood pressure :


height 5 ' 1 " , weight 138 lb.


motrin and percocet as needed .


the patient was consented for both procedures and brought to the operating room .


on postoperative day #one , she was then stable with no complaints .


this was done with falope rings .


the estimated blood loss was minimal and the patient received 600 cc. of intravenous fluid .


of note , the patient had a negative urine pregnancy test prior to the surgery .


soft , nontender , nondistended .


no history of sexually transmitted disease , no history of domestic violence .


2. undesired adiposity .


regular menses , on ortho-tri-cyclen .


appendectomy at the age of 14 , open .


the patient was admitted to the operating room where she underwent an unremarkable laparoscopic tubal ligation .


1. ortho tri-cyclen .


her foley was removed .


no masses .


spontaneous vaginal delivery x 2 .


in addition , the patient desired liposuction of varying areas as well .


she remained afebrile .


eval


if symptoms continue to be overwhelming return to v or call 1-903-263-5797


continue w/ risperdal per new psychiatrist


ptsd


.5 risperdal


b and w and work w/ therapist re: historical issues .


no calf tenderness .


cbc :


ekg showed atrial fibrillation , left axis deviation , lvh , nonspecific st-t changes either due to digitalis affect .

left axis deviation
atrial fibrillation
nonspecific st-t changes
lvh
digitalis affect


ct scan of the renal area showed right hydronephrosis which extends to an asymmetrically thickened urinary bladder wall .


heart initially tachycardia , grade ii / vi systolic ejection murmur at the left sternal border .


he was noted to have elevated bun and creatinine .


further evaluation of his renal failure showed that the patient has bilateral hydronephrosis , most likely obstructive uropathy due to prostate ca in the pelvic area .

prostate ca in the pelvic area
obstructive uropathy
his renal failure
bilateral hydronephrosis


however after the procedure , the patient 's hematocrit dropped to 24 and he was transfused two units of packed red blood cells .

two units of packed red blood cells
the procedure


the specialist concluded that because the patient 's hematuria seemed to be stable and hematocrit to maintain at about 29-30 , there is no urgent need to do an arteriogram which may cause further damage to the patient 's kidney .


this 88-year-old male with history of prostate ca was admitted from an outside hospital secondary to persistent hematuria status post nephrostomy tube placement transferred to retelk county medical center for further management .

nephrostomy tube placement
further management


the patient 's primary care physician , dr. tomedankell flowayles will manage the hospice issues .


examination was limited because the patient speaks only portuguese .


chest examination showed some basilar crackles at the right lung base .


clonidine 2.5 milligrams topical q. week , nitropaste 2 inches q.4h. , nilandron 50 milligrams p.o. q.d. , lupron , dulcolax p.r.n. , colace 100 milligrams p.o. b.i.d. , ferrous sulfate 300 milligrams p.o. b.i.d. , lansopiacole 15 milligrams p.o. q.d. , bethanechol 25 milligrams p.o. t.i.d.

bethanechol
colace
nitropaste
clonidine
dulcolax
lupron
ferrous sulfate
lansopiacole
nilandron


no palpitations , history of epigastric pain and body weight loss .

epigastric pain
body weight loss
palpitations


liver function test showed ast 21 , alkaline phosphatase 70 , total bilirubin 0.3 , total protein 6.5 , albumin 3.9 , globulin 2.6 .

liver function test
globulin
alkaline phosphatase
ast
total protein
total bilirubin
albumin


the patient was discharged to home for hospice on march 8 , 1999 .


no headache .


1. metastatic prostate ca .


pt 11.9 , inr 1.0 , ptt 28.4 .


urology consultation thinks that cystoscopy would not add any benefit to the management and only would consider a right nephrostomy if renal function failed to improve .


because of the increasing creatinine to 8.0 on february 28 , 1999 , a left nephrostomy tube was placed .


chest x-ray showed no evidence of cardiomegaly .


the patient was also given sodium bicarbonate to correct his metabolic acidosis .


bethanechol 25 milligrams p.o. t.i.d. , clonidine 2.5 milligrams topical q. week , apply every sunday , colace 100 milligrams p.o. b.i.d. , haldol 0.5-1 milligrams p.o. q.6-8h. p.r.n. agitation , niferex 150 milligrams p.o. b.i.d. , nitroglycerin paste 2% , 2 inches topical q.8h. , prilosec 20 milligrams p.o. q.d. , senna tablets 2 tablets b.i.d. , sodium bicarbonate 650 milligrams p.o. t.i.d. for five days , proscar 5 milligrams p.o. q.d. , casodex 50 milligrams p.o. q.d. , nephrocaps 1 tablets p.o. q.d.

bethanechol
clonidine
senna tablets
nephrocaps
nitroglycerin paste
prilosec
sodium bicarbonate
niferex
proscar
haldol
colace
casodex


he received transurethral resection of the prostate one year ago because of persistent urinary retention .


no bone pain .


mucous membranes slightly dry .


3. hypertension .


a long discussion amongst the specialist , nephrology , urology , interventional radiology , primary oncology as well with the family lead to the conclusion that conservative management may give the patient more comfort than crisis treatment in this well advanced prostate ca .

crisis treatment
conservative management


acute renal failure .


homan 's sign negative .


no thyromegaly .


4. anemia .


home with hospice .


after admission , the patient was treated conservatively to correct his electrolyte and metabolic acidosis .


cpk was tracked , but was totally normal .


after transfusion , the patient 's hematocrit rose to 37.7 on the day of discharge .


he continued to pass about 1500-2000 cc of urine a day and his renal function improved slowly with creatinine decreased to 4.2 on the day of discharge .


his hematocrit increased to about 30 , but he continued to have hematuria and his renal function only improved very slowly .


on admission the patient 's biochemistry showed sodium of 140 , potassium 4.0 , chloride 107 , bicarb 14 , bun 63 , creatinine 5.8 , blood sugar 133 .

creatinine
bicarb
bun
blood sugar
potassium
sodium
chloride


4) prostate ca .


prostate cancer and renal failure


prostate specific antigen increased from 77.9 to 88 , and the patient also had urinary incontinence and body weight loss .


temperature 95.4 , pulse 120 , blood pressure 150/80 , respiratory rate 24 , 95% on room air .

respiratory rate
temperature
blood pressure
pulse


wbc 8.4 , hematocrit 32.6 , platelet count 194,000 .


2. obstructive uropathy , status post left nephrostomy .

status post left nephrostomy
obstructive uropathy


a mass like thickening of the urinary bladder suggestive of either detrusor hypertrophy or possibly tumor .


he also received kayexalate for hyperkalemia .


during this admission , the patient also developed atrial fibrillation with ventricular rate of about 70-80 .


no known drug allergies .


bun was 34 and creatinine was 2.6 , up from his baseline of 1.0 .


the patient had constipation with dysuria , but no fever or chills .


mr. prehekote is an 88-year-old portuguese speaking only male who was diagnosed with adenocarcinoma of the prostate in 1998 .


history of present illness :


the ct scan showed a cavitary lung lesion in the right lower lobe compatible with metastatic or septic embolus .


he was given blood transfusion , two units when his hematocrit dropped to 29.4 .


5. gastroesophageal reflux disease .


on admission , the patient was a frail looking elderly male lying in bed in no acute distress .


allergies :


3) anemia .


due to the persistent blood in the urine , he was transferred from eifro medical center to the retelk county medical center for angiographic studies to rule out any vascular injuries .

the persistent blood in the urine
vascular injuries


no beta blockers were given .


no lung infiltrate .


ck enzymes 146 .


dr. lucreamull discussed the patient 's clinical status and overall situation with the patient 's family and the family decided that mr. prehekote could return home with hospice .


traced pitting edema .


no chest pain .


2) gastroesophageal reflux disease .


no cyanosis and no clubbing .


significant problems :


no cough .


isocoric cataract bilaterally .


no oral ulcers .


1) hypertension .


after that , he was on lupron and nilandron hormone therapy .


the patient was admitted on february 23 , 1999 to eifro medical center because of failure to thrive and decreased hematocrit .


troponin i on the second day of admission was 1.18 .


peripheral pulses were very strong and bounding .


the patient presented with a chief complaint of af-resolved .


following evaluation and treatment , the patient 's disposition at the end of the visit was treated and released .


due to difficult ambulation , the patient developed a small ulcer in the sacral area , which was treated with duoderm dressing .

difficult ambulation
a small ulcer in the sacral area


further cultures from sputum and urine revealed yeast sensitive to diflucan , which was administered shortly after .


note , please draw blood for vancomycin levels on 25 may 1998 , before the next dose , to get the trough level .


elavil by mouth 15 mg every night , dulcolax rectally 10 mg once a day , tegretol by mouth 100 mg twice a day , benadryl by mouth 25 mg three times a day , colace by mouth 200 mg twice a day , vasotec by mouth 10 mg twice a day , eoc / loc p.r./p.o. one each once a day as needed for constipation , lasix by mouth 80 mg every morning , insulin regular according to insulin scale , synthroid by mouth 25 mcg once a day , maalox plus extra strength by mouth 15 ml every six hours as needed for indigestion , milk of magnesia by mouth 30 ml once a day as needed for constipation , asacol by mouth 400 mg every morning , asacol 800 mg every night , lopressor by mouth 25 mg twice a day , miracle cream topically on skin once a day , nystatin swish and swallow by mouth 5 ml four times a day , percocet by mouth one tab every four hours as needed for pain , and vancomycin by infusion 1 gm every 18 hours ; instructions in 250 ml slow iv infusion over one hour .

indigestion constipation pain constipation

maalox plus extra strength
tegretol
benadryl
lasix
slow iv infusion
colace
asacol
miracle cream
eoc / loc
nystatin swish and swallow
asacol
vancomycin
vasotec
insulin
magnesia
synthroid
lopressor
percocet
elavil
dulcolax


vancomycin levels should be checked every third day for four to six weeks , according to imd .


insulin-dependent diabetes mellitus , lymphoma as above , ulcerative colitis , melanoma status post excision in right upper extremity , hypertension , hypothyroidism , congestive heart failure , and coronary artery disease with bypass grafting .

coronary artery disease
melanoma
hypertension
lymphoma
hypothyroidism
congestive heart failure
ulcerative colitis
insulin-dependent diabetes mellitus

bypass grafting
excision in right upper extremity


status post cholecystectomy , lumbar diskectomy , and tonsillectomy with adenoidectomy .

lumbar diskectomy
cholecystectomy
tonsillectomy
adenoidectomy


of note , the patient is status post lymphoma with treatment of chemotherapy and radiation six years ago , and is an insulin-dependent diabetic .

status post lymphoma
an insulin-dependent diabetic


due to the persistent fevers , the patient underwent vancomycin desensitization in the surgical intensive care unit followed by a change of antibiotics to vancomycin and levofloxacin .

a change of antibiotics
vancomycin
levofloxacin
vancomycin desensitization


she is now coming for surgical treatment , wound debridement , and possible wound closure with bilateral pectoralis flap .


she underwent coronary artery bypass graft times two with saphenous vein graft on 29 march 1998 .

coronary artery bypass graft
saphenous vein graft


because of expected long term antibiotic administration , a picc line was placed and the patient was prepared for transfer back to fo hospital .


the patient was admitted with a blood pressure of 140/80 , temperature 101.3 , pulse 84 , and respiratory rate 22 .

respiratory rate
blood pressure
temperature
pulse


elavil 50 mg p.o. q.h.s. , coated aspirin 325 mg p.o. p.day , tegretol 100 mg p.o. b.i.d. , ancef 1 gm iv q.12h. times seven days , vasotec 5 mg p.o. q.day , synthroid 0.025 mg p.o. q.day , asacol 400 mg q.a.m. and 800 mg q.p.m. , lopressor 25 mg p.o. b.i.d. , prilosec 20 mg p.o. q.day , and insulin 70/30 26 units in the morning and 12 units at night .

synthroid
prilosec
coated aspirin
vasotec
ancef
lopressor
asacol
elavil
tegretol
insulin


nizatidine by mouth 150 mg twice a day , insulin 70/30 human injection under skin 12 units every night , insulin 70/30 human injection subcutaneous 26 units every morning , lovenox injection under skin 40 mg once a day , and levofloxacin by mouth 250 mg once a day .

levofloxacin nizatidine lovenox insulin insulin


she is status post left knee replacement and status post multiple prior surgeries and reconstruction of the knee .

reconstruction of the knee
multiple prior surgeries
left knee replacement


the patient was switched to ampicillin , gentamicin , and clindamycin , according to the culture , enterococci and staphylococcus in the wound .


the patient is obese with unremarkable physical examination except for a systolic murmur , i / vi and erythema over the sternal wound and upper third .


there was no purulence or discharge noted .


on 10 may 1998 , she underwent sternal wound debridement and closure , performed by dr. falccouette and dr. shuffzeln .


as a small complication , the patient opened a left ankle wound post saphenous vein harvest , which persists up until now and is of a size 2 x 1 cm .


keep vancomycin trough between 10-20 , but not less due to desensitization .


sternal wound infection .


erythromycin , vancomycin , and bacitracin .


the patient was placed on iv antibiotics , ancef 1 gm q.8h.


the patient is a 74-year-old woman , well known to the cardiac surgery service , readmitted from glasmif/putdi health network with sternal wound infection .


she has been previously hospitalized on 12 april 1998 for the same diagnosis .


the wound had a beefy red cellulitic area surrounding an open area , blanching to touch .


external wound infections


on postoperative day two the patient was noted to have some swelling in her left lower extremity and this was felt to be a hematoma secondary to her pvr cuff .


small posterior tibial occlusion on the distal calf and a small peroneal goes down to the ankle .


significant for guillain-barr syndrome , lupus , status post multiple decubiti , peripheral vascular disease , status post right total knee replacement and status post cholecystectomy , status post hysterectomy , status post goiter and left lung fibrosis , status post methicillin resistant staphylococcus aureus pneumonia .

hysterectomy
cholecystectomy
right total knee replacement


trental 400 milligrams t.i.d. , cytotec 100 milligrams t.i.d. , ativan 2 milligrams q.h.s. darvon 65 milligrams two q.i.d , relafen 500 milligrams b.i.d , vitamin e , prilosec 20 milligrams once a day , zantac 150 milligrams b.i.d , lasix 120 milligrams every other day prn edema .

cytotec
prilosec
ativan
lasix
darvon
vitamin e
trental
relafen
zantac


the patient is allergic ampicillin , tylenol , clinoril , biaxin , codeine , sulfa and aminophylline .

ampicillin aminophylline biaxin codeine clinoril tylenol sulfa


her hematocrit was 26.8 and she was transfused 1 unit of packed red blood cells .


her pain resolved after surgery and she has been doing well since , although at baseline now she is minimally ambulatory from bed to commode .


abdomen , soft , non-tender , non-distended , normal active bowel sounds .


she was discharged with po keflex that she was to take for the next ten days .


the ulcer was managed conservatively at har hospital by dr. holes with silvadene b.i.d. lower extremity non-invasive study obtained at that time showed poor distal right extremity perfusion .

poor distal right extremity perfusion
the ulcer


her angiography showed a right proximal popliteal occlusion , anterior tibial dominant foot vessel .

a right proximal popliteal occlusion
anterior tibial dominant foot vessel


non-healing ulcer on the right leg .


there is mild amount of surrounding erythema and the patient was started on ancef at that time .


this patient is an seventy eight year old female with history of peripheral vascular disease who is status post above knee to fem pop bypass graft with 6 millimeter ptfe .

6 millimeter ptfe
above knee to fem pop bypass graft


for the past couple of months the patient has had a non-healing right dorsal foot ulcer which has been increasing in size and started as a pin hole and she does not recollect any trauma , as similar small ulcers developed on the left foot as well around the same time , but that has subsequently healed .

any trauma
a non-healing right dorsal foot ulcer
a pin hole
similar small ulcers


she was afebrile , her vital signs were stable .


extremities on the right , she has a ii+ femoral , no distal pulses beyond that .


she has just finished a ten day course of ciprofloxacin .


the area of erythema on her left leg enlarged slightly and the patient was placed on vancomycin for several days after which time her erythema again began to decrease .


she is status post angiography today .


she is afebrile , her vital signs are stable .


she does have rest pain in the right foot and ankle .


on a rectal examination she is guaiac negative , no masses and no gluteal ulcers or decubiti .


she has on her right ankle anteriorly a four centimeter ulcer with necrotic base .


the patient was referred back to dr. pop for the possibility of a revascularization procedure .


this operation was performed for two months of increased rest pain .


lungs decreased breath sounds at bilateral bases with minimal expiratory crackles on the right .


proventil inhaler via nebulizers 0.5 milligrams with atrovent .

proventil inhaler via nebulizers
atrovent


she denies any fevers or chills .


she had wounds which were clean , dry and intact and the patient was stable from a respiratory standpoint using her respirator at night .


neck , she has ii+ bilateral carotids , no bruits , no jugular venous distention .


on the left she has a ii+ femoral and ii+ popliteal , no distal pulses beyond that .


the patient required an additional blood transfusion during her hospital stay as her hematocrit had decreased to 27 on postoperative day three .


prednisone 5 every other day , alternating with ten every other day .


the patient was admitted and taken to the operating room on the following day and she underwent a right fem to below knee popliteal bypass graft using a six millimeter ring ptfe .


right fem to below knee pop bypass graft .


didronel 1 q day which has been on hold .


minimal surrounding erythema .


the patient presented with a chief complaint of sob .


following triage , the patient left without being seen .


ms. lenkpruskihkooglekih is a 63-year-old lady with a history of frequent premature ventricular contractions and infrequent short runs of non-sustained ventricular tachycardia ( one four-beat run ) in 1991 , for which several antiarrhythmic agents including propranolol , quinidine , procainamide , tenormin , norpace , corgard , and flecainide were used , but were stopped because of intolerance .

corgard tenormin norpace quinidine propranolol flecainide procainamide


there was no evidence of left ventricular hypertrophy or asymmetric septal hypertrophy , which had been an issue that had been raised on an echocardiogram in ownra cin , new mexico on 12/06/96 .

asymmetric septal hypertrophy
left ventricular hypertrophy


at that time , she had clear coronary arteries on coronary angiography and an ejection fraction greater than 50% .

an ejection fraction
coronary angiography


she has been on coumadin since and has continued to have occasional palpitations and mild shortness of breath .

mild shortness of breath
occasional palpitations


includes a history of hypertension ; multinodular goiter ; subtotal thyroidectomy .


she did well off antiarrhythmic agents until october of this year when she was noted to have atrial fibrillation with a rapid ventricular rate after several days of decreased exercise tolerance .

atrial fibrillation
decreased exercise tolerance
a rapid ventricular rate


the patient was discharged to home on amiodarone 200 mg daily on 12/29/96 .


a 12-lead electrocardiogram showed atrial fibrillation with a qt interval of .46 seconds .


history of multinodular goiter ; history of hypertension ; history of subtotal thyroidectomy .


the patient was started on propafenone 300 mg three times a day and underwent an attempt at electrical cardioversion after seven doses of this .


an electrocardiogram showed no evidence of qt prolongation prior to discharge , and pulmonary function tests will be performed before the patient goes home today .

pulmonary function tests
an electrocardiogram


a complete blood count , electrolytes , bun and creatinine were within normal limits .

electrolytes
creatinine
a complete blood count
bun


the propafenone was stopped , and the patient was changed to amiodarone 400 mg t.i.d. , which was continued for two days .


include cardizem cd 180 mg daily ; monopril 10 mg daily ; digoxin .25 mg daily ; and lasix 40 mg every other day .


to quinidine , procardia , and sulfa antibiotics .


there were diffuse st segment and t-wave abnormalities , which were nonspecific .


atrial fibrillation .


in addition , she will return to this hospital in early february for repeat attempt at electrical cardioversion on amiodarone .


on examination , blood pressure was 200/100 ; heart rate 120 per minute ( atrial fibrillation ) .


there was no peripheral edema .


she will continue her coumadin until then and arrangements for her readmission can be made through dr. iceca rhaltkaaispehbreun 's office here .


an echocardiogram was performed , which showed completely normal left ventricular systolic function with an ejection fraction calculated at .74 .


inr was elevated at 2.5 .


electrical cardioversion .


other than the addition of amiodarone 200 mg daily , will be the same as her admission medications .


she was started on coumadin and had a failed attempt at dc electrical cardioversion on 11/16/96 .


the abdominal examination was benign .


the patient was noted to be anxious .


there was no neck vein distension or carotid bruits .


he received rx for potassium to help with cramps .


pt 's labs were checked , he was seen by neurology , and he received a spine mri which was negative .


advised to contact pain service for repeat injections , f / u with neurology , explore pt , massage therapy .


back pain/ mechanical fall


k-dur 20meq po qd


the patient was given printed instructions for back pain ( english ) .


body shaking


3. motrin 400 mg p.o. b.i.d. p.r.n. pain .


she is to be maintained on metoprolol for blood pressure control and the restarting of her ace inhibitor is to be decided by her primary care physician .

metoprolol
her ace inhibitor
blood pressure control


transverse colectomy for tumor .


1. tylenol 650 mg p.o. q.4.h. p.r.n. pain .


when she was taking clear liquids , her pain medication was switched to p.o. pain regimen with good affect .

her pain medication
p.o. pain regimen
clear liquids


4. halcion 0.25 mg p.o. at night .


for blood pressure control she was maintained on metoprolol at the request of her primary care physician and enalapril was discontinued .

metoprolol
blood pressure control
enalapril


with the help of physical therapy the patient was ambulated and on postoperative seven , with the patient tolerating a post surgical soft diet and with pain well controlled on oral pain medications , she was discharged to rehabilitation facility .

physical therapy
oral pain medications
a post surgical soft diet


abdomen is soft , nontender , and nondistended .


heart is regular without murmurs , rubs , or gallops .


premarin vaginal once a month , enalapril , tylenol , vitamins , and halcion at night .

tylenol
premarin vaginal
halcion
vitamins
enalapril


she has also had some discomfort in her left lower abdomen and notes diarrhea every 4-5 days .


5. dulcolax 10 to 20 mg pr b.i.d. p.r.n. constipation .


she is to also call the office if she has any fever greater than 101 , bleeding from the surgical wounds , or pus from the wounds .

bleeding from the surgical wounds
pus from the wounds
fever greater than 101


cholecystectomy in 1994 , colonoscopy 2004 , status post tonsillectomy , status post appendectomy , status post orif of left wrist , status post left ear surgery , nsvd x5 , and hypertension .

appendectomy
left ear surgery
colonoscopy
nsvd
orif of left wrist
cholecystectomy
tonsillectomy


her vital signs are stable .


history of diverticulitis , status post cholecystectomy , status post appendectomy , and hypertension .


she was maintained on an epidural and pca for pain control .


she says that her appetite is good and has noted no weight loss .


baseline blood pressure of 144/61 , heart rate of 73 , and oxygen saturation of 96% on room air .

heart rate
baseline blood pressure
oxygen saturation


the patient is an 84-year-old woman with a history of diverticulitis who was found to have colon cancer on colonoscopy , which was performed in march of 2004 .


the patient tolerated the procedure well and there are no complications .


the patient reports a history of bloating and flatulence as well as increased fatigue .


her extremities are without edema and are warm .


lungs are clear to auscultation bilaterally .


the patient was consented for surgery and on the day of admission was taken to the operating room for transverse colectomy for tumor .


2. metoprolol 25 mg p.o. b.i.d.


an invasive moderately differentiated adenocarcinoma was noted in the transverse colon at 80 cm .


she was kept npo initially and her diet was slowly advanced as tolerated .


she is a pleasant well appearing elderly woman in no acute distress .


colon cancer .


on exam she is afebrile .


6. senna 2 tablets p.o. b.i.d.


no known drug allergies .


there has been interval improvement in left basilar atelectasis .


htn ventral hernia right nephrectomy s/p right facial plating


htn elev. chol. right facial droop with metal plate secondary to gsw to face right nephrectomy


no spontaneous echo contrast is seen in the body of the left atrium .


cath at kindred/north shore today showed 80% lm lesion with normal lad , cx , rca .


previously reported interstitial edema has resolved .


echo prior to scheduled cath showed mild lvh , inferior hk , ef 40% , mild mr , mild lae .


61 yo african-american-hispanic male had abnormal ekg found as part of pre-op eval. for ventral hernia repair .


status post coronary bypass surgery .


chief complaint: recent mild angina with exertion


mg - 2.1


had subsequent abnormal stress test and pefusion imaging showed ef 38% with perfusion defects .


admitted directly to or from ambulance transfer and underwent cabg x3 with dr. howard on 06-13 .


two view chest , 2017-06-17


trace mr , ai as described .


there has been removal of a swan-ganz catheter and placement of a right internal jugular vascular catheter , with the tip terminating in the proximal right atrium just below the junction with the superior vena cava .


urean - 25* creat - 1.0 k - 3.9


7. rosuvastatin 20 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


emergency cabg x 3 ( 2017-06-13 )( lima to lad , svg to ramus , svg to om )

svg to om
svg to ramus
lima to lad
emergency cabg


8. furosemide 20 mg tablet sig : one ( 1 ) tablet po bid ( 2 times a day ) for 7 days .


cad


patient recorded as having no known allergies to drugs


pt - 13.6* ptt - 33.3 inr ( pt ) - 1.2*


2017-06-17 05:14am blood


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


the aortic valve leaflets are mildly thickened .


trace aortic regurgitation is seen .


2017-06-14 02:06am blood


2017-06-13 08:05pm blood


there is mild symmetric left ventricular hypertrophy with normal cavity size .


wbc - 9.4 rbc - 3.61* hgb - 10.4* hct - 29.9* mcv - 83 mch - 28.8 mchc - 34.8 rdw - 14.3 plt ct - 154


the mitral valve leaflets are mildly thickened .


no mass or vegetation is seen on the mitral valve .


there is no pericardial effusion .


right basilar atelectasis has slightly worsened .


there is no aortic valve stenosis .


trivial mitral regurgitation is seen .


preserved lv systolic function on phenylephrine .


lvef now 50% .


transferred in urgently for cabg with dr. howard .


plt ct - 154


hct - 25.2*


ventral hernia


bisoprolol 5 mg daily crestor 20 mg daily


there are simple atheroma in the descending thoracic aorta .


foley removed on pod #2 and had scattered rales with temp 101.2 .


there are simple atheroma in the aortic arch .


afebrile the next day and pacing wires removed without incident .


i certify that i was present for this procedure in compliance with hcfa regulations .


there are simple atheroma in the ascending aorta .


no left ventricular aneurysm is seen .


there are simple atheroma in the aortic root .


severe systolic htn also noted .


the right ventricular cavity is mildly dilated .


resting regional wall motion abnormalities include mild inferior hypokinesis .


discharge instructions : may shower , no bathing or swimming for 1 month no creams , lotions or powders to any incisions no driving for 1 month no lifting > 10 # for 10 weeks


there is mild symmetric left ventricular hypertrophy .


there is no ventricular septal defect .


there is mild regional left ventricular systolic dysfunction .


overall left ventricular systolic function is mildly depressed .


no masses or vegetations are seen on the aortic valve .


no atrial septal defect is seen by 2d or color doppler .


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


2. potassium chloride 10 meq capsule , sustained release sig : two ( 2 ) capsule , sustained release po q12h ( every 12 hours ) for 7 days .


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


no mass/thrombus is seen in the left atrium or left atrial appendage .


hctz 25 mg daily lisinopril 40 mg daily


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


no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage .


the left atrium is mildly dilated .


transferred to the csru in stable condition on phenylephrine and propofol drips .


2017-06-15 02:02pm blood


extubated early the next morning and chest tubes removed .


persistent pleural effusions .


1. vascular catheter tip terminates in proximal right atrium .


2. bibasilar minor atelectasis , worse on the right and improved on the left .


gentle diuresis and beta blockade started , and he was transferred to the floor to begin increasing his activity level .


bilateral pleural effusions are unchanged .


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


no nausea , vomiting , diaphoresis .


the patient was given asa , plavix , heparin drip x 24 hours , nitro drip , atorvastatin , metoprolol , and lisinopril .

asa
plavix
heparin drip
lisinopril
atorvastatin
metoprolol
nitro drip


ck ( cpk ) - 627* ck-mb - 55* mb indx - 8.8* ctropnt - 4.46*


mchc - 35.3* rdw - 14.8 plt ct - 214


they did an ecg at bridgewater state hospital rehab which demonstarted new st depressions in v1-v4 .


ck ( cpk ) - 1288* ck-mb - 158* mb indx - 12.3* ctropnt - 6.88*


the patient is a 91 yo woman with h/o htn who came from bridgewater state hospital rehab with substernal chest pain after exercise .


2015-10-07 07:30am blood


wbc - 13.8* rbc - 3.39* hgb - 10.7* hct - 30.2* mcv - 89 mch - 31.5


glucose - 120* urean - 30* creat - 1.2* na - 134 k - 4.2 cl - 100 hco3 - 25


on presentation to providence behavioral health hospital amanda , her vitals were hr 68 , bp 142/68 , rr 28 , o2 sat 100% ra .


90 year-old woman with h/o of htn p/w substernal chest pain shortly after exercise at nursing home , with ekg showing st depressions in v1-v4 and troponin 0.07.

htn
st depressions in v1-v4
substernal chest pain


2015-10-06 04:47pm blood


ck ( cpk ) - 1471* ck-mb - 207* mb indx - 14.1* ctropnt - 6.00*


likely nstemi .


she received asa 81 mg x 2 and nitro sl x 2 with partial relief at nursing home .


the patient 's family refused coronary artery catheterization .


her metoprolol dose was increased from 25 mg po bid to 50 mg po bid then 75 mg po tid .


an echo showed that she had preserved ef and no wall motion abnormalities .


on hospital day 2 she experienced atrial fibrillation with hr in the 140s .


her chest pain was controlled with morphine .


calcium - 8.7 phos - 2.5* mg - 2.1


her sbp remained in the 160s-170s on hospital day 1 and she was gently diuresed .


she should also continue on lipitor and lisinopril .


chest pain


labs on discharge 2015-10-08 08:35am


blindness 02-26 macular degeneration


we decided given her age that she would not be a good candidate for cardioversion for her afib nor would she be a good candidate for coumadin .


* leukocytosis- she developed mild elevated wbc .


r ankle fx 2002


ua had 12-14


she can be given prn lasix for weight gain or shortness of breath .


hearing difficulty


bilateral crackles at bases and midlungs , elevated jvp , trace bilateral ankle edema , and cxr with diffuse opacities suggest possible pulmonary edema , likely secondary to acute mi .


cardiology discussed cath however , patient 's family turned down .


she should have her chem 7 checked next week given the start of her new meds .


htn


she experienced no respiratory difficulty during the hospital stay .


will also need lft 's checked in 3-6 months .


t 97.8 , hr 53 , bp 156/58 , rr 16 , o2 sat 94% on 2.5 l


her o2 sat was stable at 94-97% on 2.5l of supplemental o2 .


her cxr prior to discharge showed mild pulm edema and thus was given 40 of lasix prior to going to rehab .


her bp remained stable .


therefore we will continue rate control with metoprolol this can be titrated if needed , and aspirin and plavix for anti-coagulation .

aspirin anti-coagulation plavix metoprolol


s/p hysterectomy


ekg showed sinus brady , with old lad and new st depressions in v1-v4 .

sinus brady
old lad and new st depressions in v1-v4


tylenol prn lisinopril 5 mg po qd protonix 20 mg po qd artifical tears bid metoprolol 25 mg po bid

metoprolol
artifical tears
lisinopril
tylenol
protonix


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


exam was notable for rrr with no murmur , bibasilar crackles , guaiac negative .


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


she received asa , nitro sl then gtt , morphine , metoprolol , and heparin gtt .

heparin gtt
metoprolol
morphine
nitro sl
asa


she has a culture pending which needs to be followed up at the nursing home and treated if positive .


she was initially started on bactrim , but this was stopped as she was afebrile .


wbc 's , few bacteria .


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


trace ankle edema bilaterally


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


nad , awake , alert , blind , able to hear loud voices at l ear


soft , nt , nd , bs present , no masses


7. polyvinyl alcohol 1.4 % drops sig : 1-2 drops ophthalmic bid ( 2 times a day ) .


wbc - 11.4* rbc - 3.61* hgb - 11.4* hct - 32.6* mcv - 90 mch - 31.7


6. pantoprazole 40 mg tablet , delayed release ( e.c. ) sig : 0.5 tablet , delayed release ( e.c. ) po q24h ( every 24 hours ) .


5. atorvastatin 80 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


10. acetaminophen 325 mg tablet sig : two ( 2 ) tablet po bid ( 2 times a day ) .


jvp 11 cm


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


reg rate , nl s1 & s2 , no m/r/g


her hr decreased to 70s-80s .


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


12. lasix 40 mg tablet sig : one ( 1 ) tablet po once a day as needed for shortness of breath or wheezing :


crackles at base and mid-lungs bilaterally


11. maalox 225-200 mg/5 ml suspension sig : five ( 5 ) ml po every six ( 6 ) hours as needed for indigestion .


glucose - 124* urean - 30* creat - 1.3* na - 137 k - 4.2 cl - 102 hco3 - 27


can give 40 lasix po if having any weight gain or shortness of breath .


atrial fibrillation


mchc - 35.1* rdw - 14.7 plt ct - 281


patient without chest pain , heart rate and bp stable .


htn


please take all medications as instructed .


sinus brady @ 48 bpm , lad , lvh , rbbb , q wave in i , st depressions in v1-v4 , st elevation in iii , avf , twi in iii , v5 .

rbbb
st depressions in v1-v4
q wave in i
st elevation in iii
avf
twi in iii
lvh
sinus brady


if the patient experiences any chest pain , shortness of breath , nausea , vomiting , fevers , chills , please return to the emergency room .

chest pain
shortness of breath
vomiting
nausea
fevers
chills


she has been started on several new medications which are important to protect her heart .


angap - 12


ck ( cpk ) - 42 ctropnt - 0.07*


after returning to her room she w noted sscp without radiation .


troponin was 0.07 .


ekg :


transferred to ccu for further management and observation .


nstemi


lvef >70% , la 6.1 cm , no regional wall motion abnormality .


echo :


2015-10-05 09:00pm blood


cardiac enzymes


angap - 13


cxr 10-07 :


there is slight worsening of the still mild pulmonary edema .

the still mild pulmonary edema
slight worsening


there is no pneumothorax .


small right pleural effusion is stable .


the patient was initially maintained on intravenous fluids only and when his respiratory distress resolved he was transitioned to enteral feeds .


he is due to have his state screen sent today .


3. apnea and bradycardia of prematurity .


feeds at discharge are pe-20 currently at 120 cc per kg per day due to advance 15 cc per kg per day to a total of 150 cc per kg per day .


2. rule out sepsis , off antibiotics .


caffeine 12 mg pg q day. he has not had his 06-10 dose .


the patient has not had an cmed examination or hearing test .


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


the patient was initially started on nasal prong cpap at 6 and required additional oxygen to 35% .


1. prematurity at 30-6/7 weeks .


however by 24 hours he transitioned to low-flow nasal cannula and on day of life five transitioned to room air where he currently remains .


he was noted to have an erythematous perianal rash and for this was started on nystatin powder .


with the initiation of caffeine therapy the patient has had no more apnea or bradycardic events .


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


he was noted to have some apnea and bradycardic spells of prematurity and was therefore started on caffeine .

some apnea
bradycardic spells of prematurity


the abdomen was benign , flat , nontender , nondistended , no hepatosplenomegaly .


3. with chronic lung disease .


the neurological examination was appropriate for age with normal tone and strength and appropriate reflexes .


his most recent bilirubin was 6.6 on day of life six , the day of discharge , and his phototherapy was discontinued. he will need a rebound bilirubin level in am .

a rebound bilirubin level
his most recent bilirubin


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


he developed physiologic hyperbilirubinemia ( peak bili 8.6/0.3 on 06-08 , dol3 ) for which he was treated with a single phototherapy .


na 145 , k 4.3 , cl 110 , tco2 25 .


the morning of admission the mother developed vaginal bleeding and fetal bradycardia was noted .


hips were stable without clunk .


his admission complete blood count was notable for a white count of 11.8 , 25 polys and no bands .

25 polys
his admission complete blood count
a white count


he was given bag mask ventilation with good response .


the skin was without lesions .


the infant emerged limp and without spontaneous respiratory effort .


rpr nonreactive , rubella immune .


hematocrit was 45 , platelet count 270 .


the cardiovascular examination revealed s1 and s2 regular , no murmurs , 2+ femoral pulses .


o+ , hepatitis b surface antigen negative ,


5. feeding immaturity .


the pregnancy was unremarkable until 2015-06-01 when the mother presented to shriner 's hospital for crippled children for increased blood pressure and proteinuria .


4. hyperbilirubinemia .


neck was supple without masses or defects .


blood culture was sent but he was never started on antibiotics .


she was transferred to charles river hospital and was treated with magnesium sulfate and betamethasone .


the patient is a 1,770 gram male infant born by stat cesarean section for fetal bradycardia at 30-6/7 weeks gestation to a 29-year-old gravida 3 , para 0 now 1 mother .


apgar scores were 6 at one minute and 8 at five minutes .


the lungs were coarse bilaterally with moderate retractions .


last set of electrolytes on 06-08 , dol3 :


the blood culture remained sterile .


the patient was in mild to moderate respiratory distress .


the morning of transfer his iv came out so he has just been advanced to 120 cc per kg per day of pe-20 and his tolerating these pg feedings without difficulty .


therefore , a stat cesarean section was performed .


go to an emergency room if you experience symptoms including , but not necessarily limited to : new and continuing nausea , vomiting , fevers ( >101.5 f ) , chills , or shortness of breath .

chills
fevers
new and continuing nausea
vomiting
shortness of breath
symptoms


3. mitochondrial myopathy .


justin searle a 60-year-old man with a long history of chronic prostatitis status post two transurethral resection of the prostate procedures in 2007 and 1998 .


2. supraventricular tachycardia ( on a beta blocker ) .


turp


patient tolerated procedure on 2018-03-05 and was transferred to


he also has a diagnosis of interstitial cystitis and more significantly has a history of coronary artery disease with a recent catheterization , supraventricular tachycardia , and a progressive mitochondrial myopathy .

supraventricular tachycardia
coronary artery disease
interstitial cystitis
a progressive mitochondrial myopathy


he was started on pyridium .


interstitial cystitis


plt count - 257#


icu for 24hr post-op cardiac monitoring .


sulfonamides / penicillins / tetracyclines / azithromycin / iodine / shellfish / ace inhibitors / ciprofloxacin

tetracyclines
sulfonamides
ace inhibitors
iodine
azithromycin
ciprofloxacin
penicillins


wbc - 7.5 rbc - 5.09 hgb - 15.4 hct - 43.7 mcv - 86


please take an over the counter stool softener such as colace or a gentle laxative such as milk of magnesia if you experience constipation .

an over the counter stool softener
a gentle laxative
colace
milk of magnesia


no driving while taking pain medications .


catheter was removed .


narcotics can cause constipation .


mch - 30.2 mchc - 35.2* rdw - 13.6


proceed to the er/ew/monica if your wound becomes red , swollen , warm , or produces pus .


4. simethicone 80 mg tablet , chewable sig : 0.5-1 tablet , chewable po qid ( 4 times a day ) as needed for indigestion/gas pain .


chronic prostatitis


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


twi 's in iii , v1 .


2. atorvastatin calcium 20 mg tablet sig : one ( 1 ) tablet po daily ( daily ) .


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


abd : soft , +distension with tympany , no hsm , hyperactive bs


on hd2 , cardiac clearance was obtained by dr. sanchez .